In the 1960s and 1970s, building upon liberal theory and procedural justice, much of the discourse of medical ethics went through a dramatic shift and largely reconfigured itself into what we now call bioethics [20]. Unfortunately, the legal discourse that followed progressed more slowly, with little teeth given to those codes and doctrine that were advocated and even enacted during the latter half of the twentieth century.

The goal of the memorialization of medical ethics and jurisprudence was to affect ethical behavior through cooperation among nations and by the creation of codified agreements, through the international law aspect of the human rights efforts. Examining the levels of interventions and how health officials can make use of it allowed for the passage of laws directing the behavior of individuals and nations. Such direction becomes a major undertaking when dealing with LMICs when they themselves have not necessarily set standards for ethical and legal action. Many of these countries have undergone social and political upheaval, being referred to as conflict or post-conflict nations (e.g., Congo, Liberia, and Nicaragua). The unrest sustained has often led to governments and nations being unable or unwilling to establish ethical and legal standards to which they would adhere when dealing with the health of their population.

Global health ethics and laws that nations have enacted have inadvertently created parallel legal systems. Specifically, each individual country must approve the international ethical principles, rights, and laws that have been created before those principles are instituted within the borders of their own country. Also, a treaty not recognized by a country results in that treaty having no force of law within that country. In view of the fact that international law is developed as a “bargaining evolution of theory,” it often results in a simplified version of what was intended in order to be accepted by the multiple partners, both from developed and undeveloped worlds, participating in the process. In other words, laws and doctrine are created by compromise, often losing the initial intent and failing to accomplish hoped for goals.

Even though the Global Health community accepted the “right to health,” especially in LMICs, it did not necessarily mean that the right to healthcare was accepted. In developing countries without the resources to provide adequate care, the desire to fulfill the goals of human rights in the healthcare arena is not often met. The intent of international laws and the quest for ethical deeds in providing the right to health (care) are based on ideas, but remains only an empty fantasy without the political and financial commitment of the global community. The creation of these humanitarian concepts is admirable. But very often something that should be progressively realized only reflects promoters’ dreams by allowing the countries that most need these principles to escape any real pressure to enforce them. To bring sufficient pressure to correct this problem, human rights assessments would be necessary by unbiased observers and the results published so the facts would be universally appreciated. Anticipation of human rights violations by certain governments is required so steps can be taken to circumvent abuses [21].

The enforcement of global health laws and ethics requires an understanding of the societies that we are supposedly assisting. Developed nations must first establish that other societies are following the same rules and regulations that they have deemed appropriate. Developed nations must understand what the underlying right might be in any given society, and enforce the resolution utilizing that right. Mechanisms to accomplish this goal are available such as international tribunals that have been successful in documenting atrocities and calling to task those who have laid waste to established principles, laws, and ethics. Once the principles outlined above have been introduced, the clinical setting in which they will function starts to impact the deliverance of healthcare.

When one looks at the practical requirements of delivering “health” as established in the Declaration of Human Rights [22], the magnitude of that endeavor becomes clear. Perhaps even more than the need for surgical services in the LMCIs, is a worldwide anesthesia crisis. Most LMICs have less than 1 physician per 10,000 people and less than 1 anesthesiologist per 100,000 people, leaving an immense gap in the safe performance of operative services [23]. This void requires immediate attention to improve patient safety in low-income countries through education and support.

In order to address the marked disparity between the numbers of anesthesiologists in developed versus LCMIs (i.e., one anesthesiologist per 260 patients in the United States versus 1 anesthesiologist per 55,000 patients in Ghana) the American Society of Anesthesia Committee on Global Humanitarian Outreach is addressing this crisis in several ways:

Humanitarian efforts like these are essential in improving the state of health on a global stage.

One area of scientific pursuit in the developing world that is significantly impacted by medical ethics is scientific research. Even more than other areas of healthcare in the LMICs, scientific research raises ethical issues, especially when funded by external sponsors from developed countries. Developing countries urgently need research to help address the enormous burden of disease. The disparities in resources previously described between developed and developing countries can promote exploitation in the case of externally sponsored research. Failure to understand that external sponsors may differ in their capability to appreciate different culture and educational status of the subjects in developing countries creates the need for significant internal and external oversight of research in LCMIs. Furthermore, in order to promote the ethical and legal climate for medical research, all countries should set national priorities related to their provision of healthcare. When externally sponsored research is proposed that does not address the national priorities of its host, the research must demonstrate its relevance and be justified to an appropriate independent research ethics committee. To enhance the capability of developing countries to conduct and oversee research that is in their best interest, the inclusion of a component to improve the local expertise in country should be a provision of any new healthcare and healthcare research. The most difficult part of the creation of this monitor would be to make it independent of both external and internal forces that often have their own agendas. An independent international organization without any direct interest in the results of the therapy or research could be established to provide services equivalent to an Independent Research Committee (IRB) at any North American academic institution. The committees would be comprised of similar members as Western IRBs including physician-scientists, ethicists, and lay people. The committee would function at arm’s length from those issues on which it is evaluating and would be able to provide oversight while also performing an educational function for those in the host country. This IRB-type international committee would work hand-in-hand through every step of the process with a similar committee in the LMIC that had requested its services. The international community of developed nations would fund the program with the intent of its existence being self-limited until such time that any particular nation using it could afford its own independent organization.

Externally sponsored research often must cope with adverse and occasionally contradictory directions as to what may be ethically suitable. Finding an ethical framework for this situation requires application of the ethical and often legal principles that might be an anathema to the local authorities. In LMICs, Western ethical and legal conventions are occasionally seen as contradictory to acceptable local social and cultural behavior. An example of this is what we refer to in the West as female genital mutilation. In some countries on the African continent, this ritual is essential for a woman to be acceptable in her community and as a partner for marriage. Dealing with this type of cultural activity must be done with the utmost sensitivity. Providing such guidance and assisting in the education of those local professionals and citizens involved is part of the obligation of researchers and clinicians in establishing cohesive and mutually agreeable rules for the ethical review of research. The ethical framework for this process that has become the standard for global research is based on four principles: