Ethicists urge continuity of care for children after emergency ostomies in conflict zones

Children born with congenital colorectal anomalies, such as anorectal malformations and Hirschsprung disease, typically need several staged operations before their digestive tract can function normally. In conflict-affected settings, surgically oriented humanitarian organizations can perform the first, life-saving step—an emergency ostomy that diverts the bowel through an opening in the abdomen—but they often lack any mechanism to ensure the child later receives reconstructive surgery. A new review article in the journal Conflict and Health argues that this gap between immediate survival and long-term treatment creates a serious ethical problem that humanitarian surgery has largely overlooked.

The article, written by Yasmin Bozorgi, Émilie Joos, Mohammed Musoke, Jean-Pierre Letoquart and Shahrzad Joharifard, draws on existing literature in global surgery, conflict and humanitarian health, pediatric surgical care, bioethics and palliative care. The authors apply the Four Principles of Medical Ethics—beneficence, nonmaleficence, autonomy and justice—to analyze how care delivered under conditions of extreme constraint can pit a child’s immediate survival against long-term well-being. Their central conclusion is that while emergency ostomy creation is often ethically justified in the acute setting, the absence of reliable follow-up pathways risks exposing children to foreseeable, long-term harm.

The technical background matters here. An ostomy is only an interim measure: it keeps a child alive by bypassing the obstructed or malformed bowel, but it does not repair the underlying anomaly. Restoring intestinal continuity through staged reconstructive procedures is what allows normal bowel function. When that reconstruction never happens, the authors argue, structural barriers—including shortages of specialist pediatric surgeons, fragmented referral systems and financial constraints in conflict-affected countries—transform short-term survival into chronic morbidity. A child saved in an emergency operation may then live for years with an unrepaired anomaly, a stoma and its complications, in a health system that cannot offer the next stage of care.

The burdens extend well beyond clinical outcomes. According to the review, the absence of follow-up care imposes profound sociocultural and financial pressures on patients and their families, including stigma, gendered caregiving responsibilities and catastrophic out-of-pocket costs. These burdens, the authors note, disproportionately affect already marginalized populations. Families displaced by conflict may have to travel long distances, pay for care they cannot afford and shoulder caregiving duties that fall unevenly on particular household members, all for a condition that a functioning surgical system could have repaired.

The authors do not dismiss the practice of emergency ostomy itself. They weigh the ethical concerns against the strongest counterarguments, including the rule of rescue—the imperative to save a life in immediate danger, even when longer-term plans are uncertain. In the acute setting, they conclude, creating an ostomy is often the ethically correct choice. The problem is not the first operation but the absence of any plan for what comes after it. An intervention that is justified as a bridge to further treatment becomes ethically troubling when the far side of the bridge does not exist.

To resolve this tension, the review proposes three ethically grounded pathways. The first is establishing formal referral linkages for staged surgical care, so that a child who receives an emergency ostomy in a humanitarian facility is connected to a system that can eventually complete the reconstruction. The second is implementing structured, recurring specialist pediatric surgical programs to ensure continuity, bringing specialist teams back to the same settings on a predictable schedule rather than relying on one-off missions. The third is prioritizing palliative care when reconstructive follow-up is unattainable, so that children and families who cannot access further surgery still receive symptom relief and support rather than being left without any care pathway at all.

These approaches, the authors write, aim to align emergency interventions with long-term ethical responsibility and to offer guidance for more ethically coherent and structurally sustainable models of pediatric surgical care in conflict-affected settings. Framed through the principle of justice, the argument is that a child’s entitlement to care should not end at the moment the emergency is over; the ethical obligations of humanitarian surgical care should extend beyond the initial life-saving intervention to include planning for restoring intestinal continuity and promoting long-term recovery and dignity.

The article is published as a review in the open-access journal Conflict and Health, and the version now available is an early release of peer-reviewed, accepted research that is citable under a permanent DOI and remains subject to further edits before the final Version of Record. As an ethical and policy analysis rather than a clinical trial, it does not report new patient outcomes; its contribution is a structured argument, grounded in existing literature, about what humanitarian surgical organizations owe the children they operate on. Its practical force lies in the specificity of its proposals: referral linkages, recurring specialist programs and palliative care as a fallback are concrete mechanisms, not abstract ideals, and each addresses a distinct failure point in the pathway from emergency ostomy to restored intestinal continuity.

For humanitarian organizations working in conflict settings, the review reframes success. Saving a child’s life in the operating room is necessary but not sufficient; the ethical measure of the intervention includes whether the child can eventually reach the next stage of care, and whether families are spared avoidable stigma and financial ruin in the meantime. By naming continuity of care as an ethical obligation rather than an optional aspiration, the authors push pediatric surgical humanitarianism to account for the whole arc of treatment—and to plan, before the first incision, for how the last one will be reached.

Subject of Research: Ethical analysis of continuity of surgical care for children with congenital colorectal anomalies after emergency ostomies in conflict-affected settings

Article Title: Beyond emergency ostomies: the ethics of continuity of care for congenital colorectal anomalies in conflict-affected settings

Article References: Bozorgi, Y., Joos, É., Musoke, M., Letoquart, J.-P., & Joharifard, S. (2026). Beyond emergency ostomies: the ethics of continuity of care for congenital colorectal anomalies in conflict-affected settings. Conflict and Health. https://doi.org/10.1186/s13031-026-00858-2

Image Credits: AI Generated

DOI: 10.1186/s13031-026-00858-2

Keywords: humanitarian surgery, pediatric surgery, congenital colorectal anomalies, ostomy, medical ethics, conflict-affected settings, continuity of care, palliative care, global surgery, Hirschsprung disease, anorectal malformations, referral systems