Ethics and humanitarian action

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Ethics and humanitarian action

• Matthew Hunt
• Doctoral Candidate
• McGill Biomedical Ethics Unit
• March 11th, 2007 Global Health Course

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Objectives

• Consider the ethical dimensions of
• Global health
• Humanitarian assistance
• Health care practice and humanitarian work
• - Moral experience of HCPs in humanitarian work
• - Approaches and resources for thinking about
  moral dimensions of humanitarian work
• - Considerations for clinical electives in
  developing countries
• Cases for discussion

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Ethics and
Global health
Humanitarian assistance
Healthcare practice in HW
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Global health and ethics

• The rise of global bioethics
• Duty to care for the distant poor
• Inequity and inequality
• Another 10/90?
• Bioethics

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Global health and ethics

• Topics in global health and ethics
• What is owed to distant poor?
• Migration of health professionals
• Patents and essential medications
• Infectious diseases
• Medical tourism
• International clinical trials
• Humanitarian and development work

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Humanitarian assistance and aid

• How does international assistance get
  distributed?
• What do we hear about?

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Humanitarian assistance and aid

• Maps out a political rather than a moral
  geography
• Selectivity of aid

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MSF Top 10 underreported emergencies

• http//www.doctorswithoutborders.org/publications/
  reports/topten/
• Displaced Fleeing War in Somalia Face
  Humanitarian Crisis
• Political and Economic Turmoil Sparks Health-Care
  Crisis in Zimbabwe
• Drug-Resistant Tuberculosis Spreads As New Drugs
  Go Untested
• Expanded Use of Nutrient Dense Ready-to-Use Foods
  Crucial for Reducing Childhood Malnutrition
• Civilians Increasingly Under Fire in Sri Lankan
  Conflict

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MSF Top 10 underreported emergencies

• http//www.doctorswithoutborders.org/publications/
  reports/topten/
• Conditions Worsen in Eastern Democratic Republic
  of Congo
• Living Precariously in Colombia's Conflict Zones
• Humanitarian Aid Restricted in Myanmar
• Civilians Caught Between Armed Groups in Central
  African Republic
• As Chechen Conflict Ebbs, Critical Humanitarian
  Needs Still Remain

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How do we talk about these issues?

• Victims / rescuers
• Humanitarian emergencies

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A crisis in humanitarianism?
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• Humanitarian interventions
• The humanitarian alibi
• Negotiating with belligerents
• Sustainability
• Addressing fundamental problems vs. short term
  needs
• Dependency
• Accountability
• Human rights and local norms

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Humanitarian health practice and bioethics

• Relatively limited discussion in literature
  regarding ethical issues experienced by HCPs in
  humanitarian work
• Analysis of organizational issues much more
  developed

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The moral landscape

• The ethical dimension of this work is influenced
  by a number of important factors including
• Potentially unstable political, social and health
  situation (Banatvala and Zwi, 2000)
• Primacy of public health considerations
  (Hakewill, 1997)
• Limitation of resources (Michael and Zwi, 2002)
• Different cultural backgrounds (and ethical
  frameworks?) of the actors (Bjerneld et al, 2004)
• Contexts where regulatory guidance and oversight
  may be limited (Slim, 1997)

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What does it take to be a humanitarian health
worker?

• Have graduate degrees in anthropology, geography,
  economics know a dozen or so languages mastery
  in medicine and business administration
  competence in hydrology, accounting, psychology,
  automotive mechanics and civil engineering. They
  must also give a credible imitation of
  saintliness.
• (Susan George, 1985)

Must also be something of a moral
philosopher? (Slim, 1995)
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Principles and other frameworks
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Transferability of ethics approaches

• How do we (should we) approach moral issues in
  the context of international health projects?
• Reduced access to familiar resources?
• Reduced applicability/relevance of these
  resources?

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Ethics approaches in HW Principles

• Fundamental Humn principles
• humanity,
• impartiality,
• independence,
• neutrality,
• voluntary service,
• unity,
• universality.

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Ethics approaches in HW Principles

• Fundamental Humn principles
• humanity,
• impartiality,
• independence,
• neutrality,
• voluntary service,
• unity,
• universality.

• New humanitarian principles
• accountability,
• competence,
• appropriateness,
• respect for culture,
• participation,
• solidarity.

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Ethics approaches in HW Principles

• Medical Ethics
• autonomy,
• fidelity,
• beneficence,
• non-maleficience,
• justice

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Ethics approaches in HW Principles

• Principles of public health
• Effectiveness
• Proportionality
• Necessity
• Least infringement
• Public justification
• Childress et al, 2002

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Ethics approaches in HW Principles

• Critiques
• How do abstract principles get put into practice
  in real world situations?
• What should we do when principles conflict? How
  should we order them?
• Why one set of principles and not others?

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Ethics approaches in HW role models

• Virtue ethics
• Where to find role models?
• Mentors

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Ethics approaches in HW justice

• Justified commitments (Fuller, 2006)
• Comparative and relational considerations
• Who gets to say what is fair?
• Recipient perspectives vs national or
  international actors.

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Ethics approaches in HW

• Health and Human rights
• Address structural forms of violence
• rights or capabilities
• The role of advocacy

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Ethics Beyond Borders How Canadian Health
Professionals Experience Ethics in Humanitarian
Assistance and Development Work
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Purpose of the study

• To better understand how Canadian health
  professionals live out ethical issues in
  humanitarian assistance and development work

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Research design

• Interpretive Phenomenology (Benner, 1994)
• Semi-structured, in-depth interviews

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Participants

• 9 health professionals
• 6 nurses, 1 doctor, 1 social worker, 1 PT
• gt 8 months experience in past 7 years
• 8 different NGOs, 27 missions
• All trained in Canada
• 1 Executive Director of a NGO
• (Non-Governmental Organization)

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Tension of seeking to respect local customs and
yet not compromise own values

• Participants emphasized the importance of
  respecting local traditions and values.
• Participants struggled when following local
  approaches/views conflicted with their own deeply
  held values.

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Barriers to providing adequate care

• Constraints to the provision of basic care
  acknowledged as inherent in this work.
• Balances sought between caring for individual
  patients and the needs of the larger population.
• The need to maximize what is available and to
  attend to context (standards of care) is a
  preoccupation.

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All the basics that you come with Differing
conceptions of health and illness

• Negotiating understanding and the need to be a
  learner.
• Misunderstanding can be a source of harm.

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Looking at yourself in the mirror Issues of
identity

• The particular ethical features of this work led
  to reflection around issues of identity
• Three overlapping areas identity as a moral
  person, a professional and a humanitarian
  practitioner
• The urgency of the work often made reflection and
  deliberation difficult

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Trust and distrust

• Trust/distrust a strong thread that runs through
  the stories told by the participants.
• Building trust seen as a key to dialogue and
  working through issues collaboratively.

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Limitations of the research

• Limitations to the purposefulness of the
  participant selection.
• Development and humanitarian work may present an
  overly broad spectrum of experiences.

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Recommendations

• Relevant ethics training for humanitarian health
  professionals (case studies)
• Mentoring of new staff
• Continued development of ethics resources within
  NGOs
• Further discussion and analysis of ethics and
  humanitarian work

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An exploration of the moral experience of health
professionals in humanitarian work
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Research purpose

• The purpose of this study is to explore the moral
  experience of Canadian-trained health
  professionals during humanitarian work.

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Research Questions

• How do health professionals experience the moral
  dimensions of humanitarian work?
• What resources assist health professionals to
  evaluate and respond to the ethical dimensions of
  their work?
• What factors function as constraints to analysis
  and deliberation around ethical issues?

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Methodology

• Interpretive Description (Thorne, Reimer Kirkham,
  MacDonald-Emes, 1997 and Thorne, Reimer Kirkham,
  and OFlynn-Magee, 2002).
• Data sources
• Semi-structured interviews with HCPs (MDs, RNs,
  Nurse-practitioners, Midwives) 15
• gt 4m experience in humanitarian relief work in
  resource-poor setting.
• Interviews with NGO representatives (human
  resources, field operations) 3

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Preliminary analysis

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Health professional electives

• Excellent opportunity to learn about global
  health issues
• Things to consider
• Professionalism
• Presenting yourself as more than you are
• Taking on roles outside of your training
• Having adequate support and supervision
• Acknowledging that you may be a resource drain
  require support and time from local HCPs
• Fitting into a different medical model
• Choose carefully where you are going and with
  whom

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Case 1
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Case 2