Introduction

Interest in global health is not new. Over the past several decades, however, attention towards global health—recently defined as “an area for study, research, and practice that places priority on improving health and achieving equity in health for all people” (Koplan et al. 2009, p. 1995)—is increasing. From a financial perspective, developmental assistance for health increased from $5.6 billion in 1990 to $21.8 billion in 2007 (Ravishankar et al. 2009, p. 2117). Globally, spending by non-governmental organizations now occupies a greater proportion of developmental assistance than the United Nations and World Bank, which now occupy a relatively smaller role (Ravishankar et al. 2009, p. 2122). In the United States, funding of global health activities by the public and private sector is at a record high (Board on Global Health 2009, p. 27).

This increased focus on global health is not ethically neutral; global health is inherently an ethical enterprise. To understand this is to realize that all activities in global health require ethical judgments, whether in answering the foundational question, “Why should we care about global health?” or a more specific question, such as, “How should developmental assistance for health be best utilized?” This is true even if one removes the “achieving equity” clause from Koplan et al.’s definition, as the Board on Global Health does by defining global health as “the goal of improving health for all people in all nations” (2009, p. 18). Simply put, why anyone should care about individuals in other nations is a fundamental moral question (Singer 1972, p. 1). The forthcoming volume, Global Health Ethics, by Solomon Benatar and Gillian Brock should help substantiate the centrality of ethics to the global health enterprise (Benatar and Brock 2011).

These broad issues of global health and global health ethics are critically important. Many health care practitioners, however, do not experience “global health” in this way. Their experience frequently comes, as mine did, in the form of a short-term medical outreach or volunteer trip for the sake of improving the health of individuals in a particular low-income community. Short-term medical volunteer trips are themselves becoming a part of training in the health care professions. For example, nearly half of accredited medical schools have formal activities in “global health” (Crump and Sugarman 2008, p. 1456). Fifty-two percent of pediatrics residencies offer a global health elective (Nelson et al. 2008, p. 30). Similar data likely exist regarding other specialties and other health care professions, including nursing and physician assistant programs, as well as pharmacy schools.

If global health inherently involves ethics, then one might expect that the ethics of short-term volunteer trips would be either well-developed or an area of intense debate. Unfortunately, neither is true. Why? One hypothesis is that many individuals engaged in short-term outreach consider their activities intrinsically noble or altruistic (DeCamp 2007, p. 21), and thus not requiring of ethical scrutiny. Increasingly, however, many recognize and elaborate on the risks for harm in short-term medical volunteerism (Montgomery 1993, p. 334). This includes how short-term work can be self-serving (by offering more benefits, educational or otherwise, to those on the trip than to those in the target community); ineffective (by delivering inappropriate or unsustainable care); or costly (by diverting local resources or undermining community caregivers) (Suchdev et al. 2007, p. 317; see also Jesus 2010).

In view of these risks, this paper examines the ethics of short-term volunteer work with an emphasis on helping frame the development of ethical review guidelines. First, I highlight the need for ethical guidance. The extensive literature on the ethics of international clinical research—and the paucity of literature on the ethics of global medical volunteerism—underscores this need, particularly after realizing that the two enterprises have much in common. Second, understanding this need, the question becomes, “What makes global short-term medical volunteer work ethical?” Ethical review of short-term medical volunteerism is in its relative infancy, and requires significant collaboration with the local target community. Thus, a definitive answer is, at this point, imprudent. Nonetheless, understanding general ethical principles and engaging in a basic review process are incumbent on those involved in global short-term medical volunteer work.

A Need for Ethical Guidance

As some have suggested, the paucity of discussion surrounding the ethics of short-term volunteer work is in sharp contrast to the healthy debate surrounding the ethics of international clinical trials (DeCamp 2007; Crump and Sugarman 2008). This comparison often receives criticism when presented for discussion; therefore, a thorough explanation of it could be helpful.

In the early- to mid-1990s, controversy erupted surrounding the ethics of clinical trials conducted in developing countries by developed country governments and sponsors (Angell 1997, p. 847). The research in question involved placebo-controlled trials of AZT to prevent maternal-to-child transmission of HIV. The ethical issues, however, applied broadly to all research in developing countries: Was the use of placebo justified when clinically proven regimens were available in developed countries? How should informed consent be obtained? What counted as exploitation? Do sponsors have obligations to the community after the trial ends?

These questions, among others, stimulated heated debate (Levine 1998, p. 43) and resulted in reports and guidelines from the U.S. National Bioethics Advisory Commission (2001), Nuffield Council on Bioethics (2002), and Council for International Organisations of Medical Sciences (2002), as well as revisions to the Declaration of Helsinki (a set of ethical principles set forth by the World Medical Association to govern research). Even if issues remain unsettled (see Macklin 2004), we have arguably made progress in understanding the ethical issues in the design and conduct of research in developing countries. Guidelines exist where they once did not.

Meanwhile, global short-term medical volunteerism is increasing and yet receives relatively little scrutiny. Why is this? One reason could be that global medical volunteer work is just fundamentally different than research, and as such, does not deserve such scrutiny. This claim is terribly vague, and closer inspection reveals many similarities suggesting a dire need for ethical examination.

First, both share a complicated history of potential or actual malfeasance that impacts perceptions today. Contemporary biomedical research is affected by the Nazi medical experiments (leading to the Nuremberg Code), the alleged exploitation of subjects in African HIV prevention trials, and many other well-known cases. Similarly, contemporary short-term volunteerism is affected by a complex history of medical missionaries allegedly acting under an imperial guise.

Second, the claim that short-term volunteer work intends to benefit the target community, whereas research intends to benefit others (through the creation of knowledge) is oversimplified. Not only does well-designed international clinical research benefit the target community (in fact, tangible benefit sharing is considered by many as prerequisite to clinical research), but short-term volunteerism also clearly benefits those other than the target community. Most notably, it benefits those on the trip, educationally and experientially. For example, after my own short-term trip to Honduras, many in the group expressed sentiments such as, “I gained more from this trip than I gave the people in Honduras.” Even more telling, international clinical researchers now debate the ancillary care obligations of researchers—i.e., whether researchers are morally required to provide care for conditions unrelated to those under study (Dickert and Wendler 2009, p. 425; Hyder and Merritt 2009, p. 430). That researchers now debate these ancillary obligations that can benefit the local population underscores the similarity with volunteerism and is deeply ironic.

Third, just as research requires tangible benefits to the community, global short-term volunteerism increasingly requires research (Suchdev et al. 2007, p. 319). Research can be necessary, for example, to help identify health needs to be met during short-term work, to assess effectiveness of health interventions, and to monitor longer term health gains. Interestingly, these research aspects of short-term work require ethical review by formalized Institutional Review Boards; short-term volunteerism does not require such review.

Fourth, from the perspective of the target communities, the line between clinical research and short-term volunteerism is thin at best. One can imagine communities desiring well-run clinical research with ancillary care benefits over poorly run short-term outreach. Some of the best-designed clinical research—when it fulfills ethical guidelines regarding international research—undoubtedly results in significant tangible benefits to the community (e.g., knowledge, health care infrastructure, attention to their community’s problems, and so forth). Similarly, well-designed short-term volunteer work can often reveal areas of unmet need and avenues for clinical research.

All this suggests significant overlap between global short-term medical volunteer work and international clinical research. Nonetheless, whether this analogy holds is not essential to the overall project to develop ethical guidance and review (even if it does underscore the paucity of existing guidance). The mere risk of harm during short-term work suggests a need for ethical review (see Montgomery 1993; DeCamp 2007; Suchdev et al. 2007; Crump and Sugarman 2009; Jesus 2010).

In sum, the need for ethical guidance and review of short-term medical volunteer work is clear. The time has come to move beyond simply recognizing this; we should instead move toward answering the question, “What makes global short-term medical volunteer work ethical?”

The Myth of Mere Charity

To begin answering this question requires first dispelling a myth about global short-term medical volunteer work: the Myth of Mere Charity. The Myth of Mere Charity is a perspective often expressed in discussions about short-term work. Paraphrased, it says:

Short-term global medical volunteer work is primarily an enterprise of charity. As such, so long as minimal ethical standards are met, any particular short-term project is “ethical.”

In other words, the Myth of Mere Charity has a corollary, i.e., ethical minimalism. Understanding why this is a myth, and why ethical minimalism fails, sheds light on the general project of ethical review.

The idea that short-term work is merely charity—where charity is understood as allowing the type, amount, and beneficiary of assistance to be determined solely by the volunteer—is false, and even if it were true, it would have little import for ethical review.

It is false because it contradicts, practically, how those involved in short-term work operate. Increasingly, participants in short-term work appeal to multiple considerations when describing their focus, such as: collaboration with the community regarding health needs; education of local health care workers; and an appeal to long-term impact on health equity and empowerment. This suggests that much more than “mere charity” is involved.

Moreover, even if short-term work were simply charity, the ethical import of this is by no means clear. Importantly, obligations of charity can share many features traditionally assigned to obligations of justice, including the stringency, specificity, and enforceability of the obligation (Buchanan 1987, p. 570). In addition, many (indeed most) charitable and non-profit organizations have ethical guidelines, mission statements, and codes of conduct that reflect how even charitable enterprises have associated ethical obligations worthy of debate and discussion.

What are these ethical obligations? This is where ethical minimalism comes in. Continuing to suppose an enterprise of “mere charity,” one might suggest that because short-term work is charitable, so long as minimal ethical standards are met, any particular project is “ethical.” One way of operationalizing this would be to employ basic, time-honored principles of ethics—for example, non-maleficence, beneficence, respect for persons, and justice. If these principles are met, so the story goes, then the project is “ethical.” This ethical minimalism, however, turns out to be problematic.

For one, agreement at the level of principle in name often dissolves into significant disagreement about the content and scope of the principle in practice (Macklin 2004, p. 19). As an example, even if all agreed that “beneficence” were a valid principle for evaluating short-term work, many might disagree about what exactly counts as a benefit, how to weight benefits against risks, or how much benefit is enough. Would it be enough to treat antimicrobial infections with antibiotics, for example, or would the same resources be better spent improving the local water supply that contributes to their spread?

For another, filling out the content of even basic ethical principles requires such extensive knowledge from the local community (including its language, culture, social structure, economics, health care, and so forth) that it is hardly “minimalist.” Understanding local health needs, how to meet these needs, and how to ensure they are continued to be met—all reasonable questions in terms of “beneficence”—requires a collaborative partnership with the local community over time. To do anything less would be mere hubris. Clarifying the content of “respect for persons” in terms of local customs and social structure could be similarly complex, as volunteers ask, among other questions, “Who are the community leaders who might accept a short-term project? How are agreements reached? How does the community interact with health care workers?” If basic principles require a reasonably extensive collaborative partnership to begin appreciating their content, it hardly makes sense to call them “minimalist.”

To summarize: global short-term medical volunteerism is more than mere charity (as shown by the practical actions of volunteers and organizations), and even if it were not, significant ethical obligations exist that extend beyond falsely minimalistic ones. Importantly, however, the discussion of ethical minimalism suggests an incredibly important concept: the terms of the ethical debate surrounding global short-term work require the input of the target community at the outset—before any significant ethical review.

What Makes Short-Term Work Ethical?

Beyond these two preliminary points, much more needs to be said in answering what makes global short-term medical volunteer work ethical. To date, one of the few systematic attempts at ethical guidance for short-term work originated with the Children’s Health International Medical Project of Seattle, which works extensively in El Salvador. This group uses seven guiding principles in outlining a model for sustainable short-term international medical trips (Suchdev et al. 2007, p. 318), developed with their partners in El Salvador:

  1. (1)

    Mission: by establishing a common sense of purpose

  2. (2)

    Collaboration: with the community and its infrastructure

  3. (3)

    Education: for the community and volunteers

  4. (4)

    Service: of the community’s health needs

  5. (5)

    Teamwork: amongst the team members of diverse specialties

  6. (6)

    Sustainability: by working to build capacity in the local community

  7. (7)

    Evaluation: of outcomes and whether goals are being met

These guidelines are a useful starting point. As noted previously, however, drawing upon the comparison with international clinical research can be helpful in evaluating and improving upon these guidelines to avoid duplication of efforts.

In a 2004 article, Emanuel et al. utilize eight principles governing ethical clinical research in developing countries (Emanuel et al. 2004, p. 931):

  1. (1)

    Collaborative Partnership: with the community

  2. (2)

    Social Value: to the community and its infrastructure

  3. (3)

    Scientific Validity: of the research

  4. (4)

    Fair Selection: of the study population

  5. (5)

    Favorable Risk–Benefit Ratio: of the research intervention

  6. (6)

    Independent Review: of the research project before it commences

  7. (7)

    Informed Consent: in a community-accepted manner

  8. (8)

    Respect for Participants: through adequate confidentiality and information

The parallels between the two lists are striking, and the latter list offers a few areas where guidelines on short-term medical volunteerism might be improved. To this end, a proposed modification and simplification of the Suchdev et al. (2007) guidelines is offered in the following.

Ethical Principles to Guide Global Short-Term Medical Volunteer Trips

Statement of Purpose: Toward Global Health Equity Through an Expression of Mutual Caring

Similar to the mission statement of Suchdev et al. (2007), a clear sense of purpose for short-term work is crucial. Not only does it help shape how the following ethical principles gain meaningful content, but it also provides accountability to the endeavor. In a subtle shift from their framework, however, this purpose is not sustainability per se. Sustainability itself is only a means to an end. Regarding short-term volunteerism, this end should be greater global health equity through an expression of mutual caring and the relief of suffering. The focus is on long-lasting change; indeed, one hopes for non-sustainability of the short-term project—assuming that means the medical volunteers are no longer needed. All global short-term medical volunteer trips should develop their own statement of purpose geared toward global health equity and mutual caring. Following on this statement, the following seven principles further guide ethical review.

Establish a Collaborative Partnership

Establishing a collaborative partnership with the local community and amongst the team of volunteers is critical, not just for ensuring that short-term work is ethical but also for ensuring it is successful. This partnership begins before the statement of purpose is crafted and continues before, during, and after the volunteer trip(s). Only through a true partnership is respect shown toward the individuals in a target community. “Informed consent,” as strictly interpreted in the research setting, does not apply directly, but the spirit of it does. In short, a collaborative partnership seeks to empower the local community and reduce, if not eliminate, the sense that they are mere recipients of aid. This partnership of equals has practical import. It makes it unethical, for example, for individuals to practice outside their expertise in a foreign environment. It also assumes reasonable knowledge of local language and culture. Moreover, this collaboration (when started early enough) is absolutely necessary to understand the other ethical principles below. Ethical principles are no more the exclusive domain of individuals in high-income countries than medicine is, and should not be imposed (for example, by imposing the type of benefits sought or written requirements of informed consent).

Ensure Fairness in Site Selection

Fairness in site selection is a critical part of the ethical review of short-term work, just as it is for international research. Short-term work locations are chosen because of existing personal contacts; familiarity with the local culture or language; perceived medical need; efficiency of resource impact; and many other reasons. Given the extent of global health inequity, however, needs almost always outstrip supply. Therefore, the reason for choosing a local target community should be clear, and includes the rationale for why a global project is necessary in the first place (e.g., might a local project meet similar educational objectives?). An example of inappropriate site selection, for example, could involve sending short-term volunteers to an area where an individual or institution will reap inappropriate political gains or create a sense of indebtedness that could be exploited.

Commit to Benefits of Social Value

A frequently discussed ethical imperative in short-term work is ensuring that the community will truly benefit from the intervention. This is a question answered mainly by the community itself, by ensuring that the work is desired and feasible (or with a reasonable likelihood of benefits outweighing risks). Benefits might be both short-term and long-term, depending on the setting. In some cases, the needs identified by the community might not agree with the needs as assessed by the volunteer group. In those cases, which can be navigated through collaboration, deference should be given to the local community. Importantly, some benefits that weigh into a short-term trip accrue to the volunteers, as they learn about medicine in other cultures. These benefits do count in the risk–benefit calculus, so long as they are in line with the trip’s collaborative purpose toward greater global health equity through mutual caring.

Educate the Local Community and Team Members

Global short-term medical volunteer work is somewhat unique in its strong focus on education, as shown by the increasing involvement of medical, nursing and allied health education involvement in them. This is not surprising, as education is a cornerstone of increasing awareness as a way to foster long-term change. Ensuring that education operates in both directions is also critical, even if in many cases the high-income country team will learn more than the local community. Educational benefits to the volunteers should not become an end in themselves, however. Groups should repeatedly assess whether the educational gains (which in some cases reduce the efficiency of the short-term work) are justified. For example, short-term trips that seek to expose individuals to medicine in the low-income setting for the first time might find it unreasonable for the same individuals to attend the trip in that capacity year after year.

Build the Capacity of Local Infrastructure

Capacity building is such an important aspect of global health work that it cannot be subsumed under “social value” (number 3 above). Not only should short-term work not interfere with local infrastructure (by displacing or disenfranchising local health care workers), it should seek to build on and improve this infrastructure. Doing so involves more than just building clinics or starting health care worker training; it should also involve empowerment of the local community’s voice. For example, communication infrastructure that plugs a community into the internet and allows it to fight for greater global health equity through fostering social movements could be just as valuable as a new hospital ward.

Evaluate Outcomes

Ethical clinical research is scientifically valid and takes seriously its outcomes. The same is true of global short-term medical volunteerism. Outcomes in this sense are broader than the medical outcomes of individual patients, and the outcomes measured depend in part on the ethical justification for the trip in the first place. For example, a trip involving a particular education initiative on wastewater management should document that its education message is effective. Another trip meant to expose students to health care abroad and stimulate interest in global health ought to see if these students indeed are more likely to pursue global health in the future. Most importantly, if evaluation reveals unmet objectives, modifications to the work should be pursued.

Engage in Frequent Ethical Review

Ethical review of global short-term medical volunteerism is prerequisite for this work, and should be performed regularly before, during, and after volunteer efforts. This is again analogous to clinical research, where institutional review boards or ethics committees review work prior to it commencing and (at least) annually thereafter. Educating team members and involving them in this review is one part of this goal. Of course, when volunteer work involves research, this research will require formal institutional review board (IRB) review. How ethical review of short-term work might proceed, based on the above principles, is the subject of the next section.

These seven principles and statement of purpose provide an initial framework of principles for ethical review that builds on the efforts of Suchdev et al. (2007) using some concepts employed by Emanuel et al. (2004). Now included are specific references to fair site selection and ongoing ethical review. Key elements of collaboration and teamwork, social value, and capacity building are maintained, while the focus shifts slightly from one of sustainability to one of achieving greater global health equity through mutual caring.

The above principles are vague by design, and several caveats are worth noting. First, the content of these principles requires additional elaboration in a project-specific manner done through collaboration with the target community. In this way, questions derived from the principles obtain: Why has this site been chosen? What are the expected benefits, what is the risk of harm, and to whom do benefits accrue? What educational benefits exist? How will infrastructure be improved? What outcomes will be measured?

Second, following the lead of Emanuel et al. (2004), answering these questions requires the development of project specific benchmarks to ensure that stated objectives are being met. Benchmarks might include health and non-health related items that are specific enough to provide accountability. These benchmarks come via collaboration.

Third, principles may conflict. For example, educational objectives might conflict with attaining the greatest benefit for the local community, as trainees work less efficiently. In some cases, respecting the community might mean pursuing a project that an outside observer thinks is less important. Caring for the sick now through the relief of suffering might not work toward the greatest gains in long-term global health equity, but is still important. Acknowledging these conflicts is important, and might help foster ways to minimize or eliminate the conflict.

How Should Ethical Review Occur?

One of the principles above—frequent ethical review—deserves additional clarification. Although the literature around global short-term medical volunteerism corroborates in various places these principles, comparatively little is written about how ethical review might occur.

Returning to the comparison with international clinical research, one might propose a modified institutional review board (IRB) model for the review of short-term work. For several reasons, this would be premature.

First, the origin of IRBs in the United States as a federally-mandated body governing research oversight was in response to ethical transgressions in clinical research. While ethical transgressions in short-term work have occurred in the past, the federal context of research is decidedly different than global medical volunteerism. It is hard to imagine requiring federal oversight of this work. An additional disadvantage of this federal system is how is can result in two review committees—one in the high-income country, and another in a low-income one. This arrangement is contra the spirit of collaborative partnership envisioned here, where one committee would be preferred.

Second, even if taken on a smaller scale (e.g., institutional review committees modeled on IRBs but not required by federal regulation), significant limitations exist to IRB-type review. One limitation is that the content and benchmarks of the ethical principles remain relatively open. Unlike modern IRB review, where boards have substantial guidance which is openly and freely debated at national conferences, no analogous guidance yet exists for global volunteerism. Another limitation could be that the instantiation of ethical principles in different geographic regions, cultures, and types of projects could be such that a single review committee is impractical. Finally, and most importantly, the real question is whether the additional time and resources spent on an IRB-modeled review process could be justified, as opposed to spending those resources toward the project itself. Because of the uncertainties described above, instituting this type of review would be imprudent.

Nevertheless, ethical review of short-term work cannot wait, and some characteristics of IRB review are valuable and should be shared. These include its relative independence; its formalized review process, which includes documentation; and its repeat assessments at regular intervals.

Involving independent individuals in the ethical review of short-term work can add new perspectives on ethical guidance. Review of short-term volunteer work should not be wholly independent, however. In fact, as described above, collaboration with the local community is necessary to define the terms of the review in the first place, including ethical principles and their benchmarks. In most cases, including independent and involved parties will greatly aid the review process.

A formalized review (though not necessarily as formal as IRB review of clinical research) is also important. This could include a structured process, beginning at the brainstorming stage of trip planning, that involves the local community and documents how the project conceives of its goals, ethical commitments, and benchmarks. Documentation is important, in so far as it creates accountability, aids analysis, and provides one part of a project’s written history.

Lastly, frequent ethical assessment and reassessment are imperative. Having written documentation facilitates this goal. In addition, as projects change over time, so will the ethical implications of the work. Repeat assessment at appropriate intervals (e.g., annually, after returning from trips, or another reasonable timeframe) allows project participants to respond to changing circumstances.

At some point, having an analogue to IRB-review could be possible for short-term volunteerism. Until that time, however, projects might be advised to conduct their own ethical review in a frequent, semi-independent, and structured manner.

Additional Dimensions of Ethical Review

As if the ethical review of global short-term medical volunteerism were not complicated enough, in this final section, the situation becomes even more so. In recent years, the ethics debate has focused mainly on academic settings, probably due to the surging interest in global health in these settings. While this increased attention is welcome, it risks painting a skewed picture in favor of those issues unique to trainees and academic institutions. Ethical issues related to trainees’ practicing in foreign settings (perhaps beyond their expertise) and academic institutions’ responsibility for the education and safety of their enrollees are critically important. However, given the variety of institutions and individuals involved in short-term work, the debate at this point should be as broad as possible, and include individuals from a multitude of settings.

To this extent, those involved in ethical review should keep in mind the following dimensions of projects:

Type of Institution. The major ethical issues identified for particular projects will often relate to the type of institution (or institutions) involved in the collaboration. As just mentioned, academic institutions should address issues specific to trainees, including how educational objectives might conflict with service objectives of the project. Other institutions frequently engage in this work, however. Private, for-profit companies should ensure that their profit earning objectives or specific products do not interfere with project goals. Non-profit organizations and governmental groups should be cautious regarding organizational or political motives that might interfere with the project. Acknowledging these issues is a necessary first step to resolving them as part of ethical review.

Type of Intervention. Ethical issues will also vary according to the type of intervention or project proposed. For example, some trips, such as those responding to extremely short-term needs (e.g., natural disasters or acute surgical needs), will focus more on acute interventions to benefit the local community and less on long-term projects. Others, such as those continuing with chronic care management (e.g., HIV treatment), will necessarily focus more on capacity building and collaboration with local caregivers. Similarly, some projects might focus more on educational initiatives and infrastructure development then acute care. Ethical review must take into account these differences and not propose a one size fits all approach.

Type of Relationship with the Local Community. Short-term global medical volunteerism, as its purpose implies, is properly thought of as a process toward greater global health equity and mutual caring. For this reason, the ethical principles above do not define “short-term.” Individual projects will occur at different stages of a relationship with the local community. A trip that begins as a one-week clinical and educational intervention with a community abroad where collaboration has only recently begun will have different ethical obligations than one where the partnership is longstanding. This does not translate to lower ethical standards for a newly formed collaboration. It might, however, result in different content and benchmarks for the principles described above.

Conclusion

Global short-term medical volunteerism is growing, and properly conducted, is a tool in the fight for greater global health equity. It is intrinsically “ethical” (i.e., it involves ethics at every step) and depends upon ethical conduct for its success. At present, ethical guidelines remain in their infancy, which presents a unique opportunity. This paper has presented a set of basic ethical principles, building on prior work in this area and previously developed guidelines for international clinical research. The content of these principles, and the benchmarks used to evaluate them, remain intentionally vague and can only be filled by collaboration with those on-the-ground in local communities where this work occurs. Ethical review must additionally take into consideration the different obligations arising from the type of institution, type of intervention, and type of relationship involved. Additional discussion on these principles and ethical guidance is needed. Nonetheless, frequent and formalized ethical review, conducted from the beginning with the local community (where this community helps define the terms of debate), remains the most important ethical safeguard for this work.