The issue of which sites visitors/organizations choose to help with human and fiscal resources is a matter of resource allocation and fairness. What is the decision-making process going into the selection of a host country that will receive benefit from a given surgical educational mission? Beyond a valuable medical exchange, these missions also typically provide donated resources, educational materials, and exposure to new skills that together can lead to regional inequity when distributed unfairly. How then do we determine where to allocate these human and fiscal resources? Why does site A in sub-Saharan Africa have a lot of outside help whereas no one goes to sites B and C? While no specific data exist on selection method, anecdotal evidence suggests location of surgical missions has been facilitated by ease of access such as safe travel, available infrastructure, a common language, and networking between organizations or friends.

To approach the decision from the ethical principle of justice as fairness, it would seem desirable to perform a needs assessment and have a transparently visible list of networks or institutions that are targeted for help over a specific timeline. While sociopolitical contexts will influence decisions, a solution might be for visiting surgeons to keep a 10-year plan that enables selection to vary based on regional stability, influx of new resources, or increased need. In this way, those requesting help can feel ethically satisfied that their request will receive consideration. Ultimately we must all be globally accountable. Human and fiscal resources are valuable and finite and merit being shared as broadly and fairly as possible, avoiding duplication of efforts. Without a centralized repository of past and ongoing surgical missions, accountability has been lacking. Responsibility for ensuring fair resource allocation must be shared, between visitors and hosts. It is promising to see online access to surgical education initiatives (Canadian Network of International Surgery 2011) and records of surgical equipment donations or subsidized costs made available by the World Federation of Neurosurgical Societies (World Federation of Neurosurgical Societies 2012). A shared process must be obtained wherein visiting teams must ensure they only go where they are wanted and/or needed and where the local surgeons have expressed a desire for engagement in international surgical education.

Sustainability is critical in global health development and international surgery specifically. A key issue that arises is the question of whether a new technique or piece of equipment can be sustained after departure of the visiting team (Haglund et al. 2011; Howe et al. 2013a, b). Skill translation is only one aspect of sustainability; success also depends on other issues such as technology-based needs (e.g., imaging or surgical drills), surgical supplies (e.g., surgical hardware), system capability and infrastructure, and institutional commitment. Often equipment that is brought cannot be properly maintained or serviced or is brought for demonstration purposes but not left behind. An example would be a cortical stimulator to teach awake craniotomy which is transported back home because they are too costly to leave behind.

The ethical principle of maleficence arises when we ignore our initial plan and albeit unintentionally embark on surgeries that leave patients incompletely treated, hosts incompletely trained, and ultimately produce a greater societal burden. Planning for sustainability is possible and might include a feasibility assessment that determines how well a given technique can be implemented in resource-limited settings where infrastructure is inadequate or is unpredictable. The simplest procedures to teach are likely the best – those that are less invasive, need less equipment, need less operating and recovery time, and produce less complications. Similarly, sustainability in surgical education might include skill enhancement in the domains of related disciplines like nursing, anesthesia, administration, and management practices to build broad-based capacity. Operation Smile has demonstrated the effectiveness of surgical educational missions on creating local sustainability and capacity building by showing that the number of patients treated by international surgical teams has decreased from 100 % initially to the current 33 % worldwide during a 20-year term (Magee et al. 2012). We need to strive for the same in neurosurgery although the metrics will be challenging.

Another important piece in knowledge transfer includes bringing colleagues from resource-poor settings, residents, and consultants to our hospitals in resource-rich settings for observation periods or clinical fellowships. This can help complete the training of a neurosurgeon. This will require expenditure of human and financial resources on the part of surgeons committed to overseas collaborations.

Expectations can be mismatched or even unfair on both sides. Expectations of hosts placed upon the visitor performing in conditions less optimal that what he/she is used to or performing surgeries for which he/she no longer feels qualified are problematic, but visitors should prepare as best as possible for these situations. Often, the visiting specialist is seen as an outright authority and expert, as opposed to a colleague with whom clinical problems can be discussed and solved in a shared manner. In this setting, we must balance the idea of doing “good” with the ethical principle of non-maleficence.

On the other side the visitors often place expectations on the local surgeons like being as organized as the visitor, being as timely with e-mail responses, and providing excellent preparation of the cases and other activities relating to the visitor’s time. When expectations of either group are not adequately met, it can lead to frustration and tension which can impede the desired effective transfer of knowledge.

This relates to the ethical dilemma of appropriate team selection for an educational surgical mission in a resource-poor country and again relates to resource allocation. To date, very few groups have described the rationale or criteria for which types of health-care professionals to include, but it would seem to be obvious. Regarding the makeup of the team, would it be beneficial to take anesthetists, operating room nurses, and/or residents? Evidence is emerging indicating the benefits of surgical education for residents in a resource-limited setting (Jarman et al. 2009). In some cases, however, a more useful team member might be a biomedical engineer. The above can play a key role in ensuring sustainability and capacity. When a medical student goes on a mission with a surgeon, the experience will likely be of benefit to them, but how much can they contribute to the local surgeons?

Regarding the quality of the team, culturally sensitive team members who can promote good cultural exchange are essential. Team members must be skilled, knowledgeable, have the capacity for good cultural rapport, and be open to experiencing different cultures. While team selection is specific to the goals of a given mission, it is critical to acknowledge the existence of ethical dilemmas faced during this process and address them. Above all, team members must want to participate for the right reasons, be capable of good teamsmanship, and be open to new cultures and interactions that may require adaptive behavior in unfamiliar settings (Welling et al. 2010; Howe et al. 2013a). Appropriate preparation of the team members by the team leader is essential.