MSS911: ETHICAL CHALLENGES ENCOUNTERED ON INTERNATIONAL MILITARY SURGICAL ENGAGEMENTS
Debashree Mitra, MD1; Pranish Katwal, MD2; Tamara Worlton, MD3; 1Naval Medical Center San Diego; 2San Antonio Military Medical Center; 3Walter Reed Military Medical Center
Introduction: Military surgeons face distinct ethical challenges during Department of Defense (DoD) Global Health Engagements (GHE), particularly in direct patient care missions. Unlike civilian global surgery or surgical volunteerism, DoD GHE is shaped by strategic objectives, resource limitations, and unique cultural dynamics. While individual reports have described ethical concerns, few studies have aggregated experiences across regions and mission types. This study aims to examine the prevalence of pre-engagement ethical and cultural training and to identify common ethical themes reported by military surgeons during international surgical GHE.
Method: A mixed-methods approach was employed using survey data from military surgeons who participated in various DoD GHE. Quantitative analysis characterized the regional distribution of missions and the provision of ethical or cultural pre-engagement training, with associations tested using descriptive statistics and chi-square tests. Qualitative analysis of free-text responses was conducted using Braun and Clarke’s thematic framework to identify recurring ethical challenges.
Results: Fifty-six responses were analyzed, with most missions conducted in the U.S. Southern Command (23) and Indo-Pacific Command (17). Pre-engagement training varied significantly by region (p = 0.028), with no training reported in U.S. Central Command missions. Eleven ethical issues (19.6%) were reported, 72.7% of which arose during hospital ship missions. Respondents identified four overarching themes: (1) cultural challenges, including misunderstandings of local customs and differing views of consent; (2) ethical dilemmas, such as pressures to perform surgeries below U.S. standards of care or on inadequately optimized patients; (3) systemic issues, including nepotism, political influence, and lack of postoperative continuity; and (4) relational dynamics and trust, particularly tensions with local providers whose livelihoods and reputations could be jeopardized by complications. Additionally, 48% of respondents reported complications, including six major events and three deaths, raising concerns about follow-up care and sustainability.
Conclusion: This study underscores the indispensable need for tailored ethics training for military surgeons engaged in direct patient care during GHE. There is possible benefit in standardized curricula addressing informed consent in cross-cultural contexts, delineation of patient responsibility, and strategies for collaboration with host nation providers. The findings also highlight risks of moral distress when surgeons are unable to align care with their professional standards. Future research should evaluate the long-term impact of ethics-focused pre-engagement training, assess best practices for mitigating systemic challenges, and develop policies to ensure ethical, sustainable, and partner nation-centered surgical engagements.