**5. Summary**

Pediatric cardiac global surgical initiatives have significantly increased in number and coverage over the last 25 years. The benefits to the children, their families and the local healthcare professionals are clear. However, it is possible to create discontent with the program if ethical pillars are violated. The result will be program failure. Providing autonomy for local stakeholders and parents is critical to promote confidence and trust, remembering that our primary concern is the patient and that one must practice non maleficence is important for perceptions within the local community and our first responsibility as physicians. The principle of justice runs throughout the development of pediatric cardiac programs in LMIC, it impacts all aspects from patient care to education of local healthcare professionals to allocation of resources. Following ethical principles will result in an independent locally driven program in pediatric cardiac care if all stakeholders adhere to these principles.
