Controversies in the conduct of international research continue to pose challenges for the system of ethical review, particularly for developing countries. Although the concept of vulnerability is key to addressing these challenges, ethical review has typically ignored the agency of vulnerable participants and groups in determining what kind of review process is needed. Concurrent with developments shaping the new public health that seek to operationalize empowerment of communities by placing them as initiators and organizers of their own health, ethical review of public health research must find ways to recognize the agency of vulnerable individuals, groups, and communities in the review process if it is to address effectively the ethical dilemmas currently evident in collaborative international research.