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

Abstract Background Children born with congenital colorectal anomalies, such as anorectal malformations and Hirschsprung disease, typically require multiple staged surgical procedures. In conflict-affected settings, surgically-oriented humanitarian aid organizations perform emergency ostomies in pediatric patients as initial life-saving interventions, but often lack mechanisms to ensure subsequent reconstructive care. Main body This article draws on existing literature in global surgery, conflict and humanitarian health, pediatric surgical care, bioethics, and palliative care to critically examine the ethical, structural, and sociocultural implications of this practice. Using the Four Principles of Medical Ethics – beneficence, nonmaleficence, autonomy, and justice – alongside other ethical frameworks, we analyze how care delivered under conditions of extreme constraint may create tension between immediate survival and long-term well-being. 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. Structural barriers, including specialist workforce shortages, fragmented referral systems, and financial constraints in conflict-affected countries, further compound this ethical tension by transforming short-term survival into chronic morbidity. Beyond clinical outcomes, the absence of follow-up care imposes profound sociocultural and financial burdens on patients and their families, including stigma, gendered caregiving responsibilities, and catastrophic out-of-pocket costs, which disproportionately affect already marginalized populations. We weigh these concerns against the strongest counterarguments, including the rule of rescue, before proposing ways forward. Conclusion Our analysis suggests that 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. We propose three ethically grounded pathways: establishing formal referral linkages for staged surgical care, implementing structured, recurring specialist pediatric surgical programs to ensure continuity, and prioritizing palliative care when reconstructive follow-up is unattainable. These approaches aim to align emergency interventions with long-term ethical responsibility, and offer guidance for more ethically coherent and structurally sustainable models of pediatric surgical care in conflict-affected settings.