Surgical stewardship: balancing the ethics of withdrawal and the justice of adoption

Surgical innovation in high-income countries is currently defined by a paradox: the relentless pursuit of complex, high-cost technologies persists alongside a systemic failure to de-implement wasteful practices and a reluctance to adopt proven, frugal solutions from low- and middle-income countries. Frugal innovation refers here to the development or adaptation of safe, effective and affordable solutions designed to maximise value under resource constraints. This article argues that these twin failures are not merely logistical but are reinforced by structural inequities and by the unequal valuation of knowledge according to where it is produced. By examining the moral symmetry between the duty to ‘unlearn’ low-value procedures (de-implementation) and the duty to learn from frugal innovation (reciprocal innovation), the systemic barriers of rigid evidence hierarchies and regulatory biases are exposed. A new professional ethic for global surgery is proposed, one that redefines progress not as accumulation, but as the equitable stewardship of shared knowledge and limited resources.