**3.2 Infrastructure issues**

*Bioethics in Medicine and Society*

education, training, experience and optimal patient care which can be violated without adequate thought, preparation, and execution. Moreover, legal issues with the importation of medicines, supplies, equipment, and licensure must be considered on a country-by-country basis. Critics of surgical development assistance in general and cardiac specifically abound, some with relevant points. It is incumbent of those assisting to do so within the scope of ethical standards both from the visiting team's country and the country receiving assistance if success is to be assured.

The overarching goal of cardiac assistance should be the development of an independent program of cardiac care capable of sustainability. Depending on the local situation such an endeavor may take only 2–3 years for a pre-existing program to as many as 7–10 years if you are building a program *de novo* [3, 4]. The timelines are not firm, as the major determinants of the speed of development are local leadership, visiting team commitment, consistent funding, and a supportive

Good intentions without trust by all sides will result in a failure of development. Building relationships is critical to the success of advancement and attainment of the primary goal. Therefor it is important from the outset to create an environment that results in the delivery of the promise and goals. You cannot develop relationships and trust if you do not provide the opportunity for the local team to participate and grow through a program of mentored graduated responsibility. Those teams that provide services only and allowing only limited participation by the local team are not upholding the promise and as such trust will not be developed and a rapid disconnect will occur, thus dooming program development. There are few times and places where the local team cannot be developed, and the visiting team simply provides all the care without education [5]. Beneficence cannot be directed at only the children receiving operation at the time of a visit, this is only a part of truly doing good work. One must consider the local team and the children that are still waiting for surgery and those not yet born. The idea of assistance is to build a

Before undertaking a program to develop pediatric cardiac services there must be an agreement between all stakeholders regarding what level of development is desired by the local team. Autonomy of choice by the local team is imperative, one should not approach this as *we know what is best for you and your country,* this is a form of neo-colonialism and is to be avoided [6]. You may be experts in pediatric cardiac care, but they are certainly the experts in the subtleties of politics and

Once a decision is reached regarding the level of expertise the local team wishes to attain it is critical to identify clinical leaders in surgery, critical care, anesthesia, perfusion, and pediatrics. Once again, the autonomy of the local team is important here, they need to decide amongst themselves who will lead the various specialties involved in the care of children with heart disease. There is simply no justification for the visiting team to insist upon certain individuals being named to leadership positions. Such an attempt will lead to a fracture of trust and the development of

**2. Intentions of cardiac care development assistance**

government. The key component to all the above is trust.

program that benefits many children for years to come.

**3. Implementation of the development program**

**3.1 Direction and leadership**

economics of their countries.

**240**

One does not often relate ethics and infrastructure, but when considering the creation or improvement of an existing pediatric cardiac program you must be sure that the necessary elements for providing safe pediatric cardiac care are in place or will be before program initiation. The equitable treatment of the children receiving care in LMIC must be maintained within the constraints of economic reality. The deficiency in pediatric cardiac caregivers in LMIC has resulted in large waiting lists and the needs of the many outweigh the needs of the one. Although ECMO, artificial hearts and left ventricular assist devices can provide a few children in upperincome countries (UIC) with a survivable situation, but when costs are considered many more children could be saved in LMIC with a low-risk operation. Basic infrastructure needs for pediatric cardiac care include an echocardiogram machine, an operating theater (not a hybrid OR suite) adequately provided with climate control, oxygen, air and electrical sources in addition to anesthesia machine and routine open heart surgery equipment. A basic intensive care unit with invasive monitors, adequate oxygen and electrical sources and ventilators to provide routine care. The vast majority of children requiring surgical intervention will be adequately served with these essential elements [8]. A cardiac catheterization lab is a luxurious addition to the diagnostic equipment and justification for this is difficult in a number of LMIC. However, the possibility of acquiring a refurbished catheterization laboratory rather than a state-of-the-art device is a means of providing this diagnostic capability and creating an equitable situation. A donor who provides such sophisticated equipment must be prepared to continue to support the maintenance or the equitable situation they created in diagnostic capabilities can be short-lived. There is simply no justification for providing advanced diagnostic equipment, having the local team develop capacity with it, and then having it removed because of a breakdown and an absence of support for repair [9].
