Humanitarian Action and Ethics

Ayesha Ahmad, James Smith, Ayesha Ahmad, James Smith

• Publisher: Zed Books
• Year: 2018
• Print ISBN: 9781786992680
• eBook ISBN: 9781786992703
• Edition: 1
• Topic: Social Sciences
• Subtopic: Higher Education
• Index: Social Sciences

From natural disaster areas to conflict zones, humanitarian workers today find themselves operating in diverse and difficult environments. While humanitarian work has always presented unique ethical challenges, such efforts are now further complicated by the impact of globalization, the escalating refugee crisis, and mounting criticisms of established humanitarian practice. Featuring contributions from humanitarian practitioners, health professionals, and social and political scientists, this book explores the question of ethics in modern humanitarian work, drawing on the lived experience of humanitarian workers themselves. Its essential case studies cover humanitarian work in countries ranging from Haiti and South Sudan to Syria and Iraq, and address issues such as gender based violence, migration, and the growing phenomenon of 'volunteer tourism'. Together, these contributions offer new perspectives on humanitarian ethics, as well as insight into how such ethical considerations might inform more effective approaches to humanitarian work.

1 | DIFFICULT DECISION-MAKING, COMPROMISE, AND MORAL DISTRESS IN MEDICAL HUMANITARIAN RESPONSE

James Smith

Introduction1

Humanitarian actors are often faced with multiple and repeated pressures in challenging and dynamic contexts. The practice of humanitarian medicine in such situations regularly demands that staff make difficult decisions, which in turn can have significant ethical implications. In ‘Compromised Humanitarianism’ Cullity (2010: 155) draws on the same fundamental premise to ask, ‘how can humanitarianism operate in such conditions [as it characteristically must] without itself becoming morally compromised?’

For an organisation like Médecins Sans Frontières/Doctors Without Borders (MSF), which actively ‘rejects the idea that poor people deserve third-rate medical care and [in turn] strives to provide high-quality care to patients’ (MSF, n.d.) making concessions during the implementation of programmes can be the source of profound moral discomfort.

As a partial response to the difficulties inherent in humanitarian decision-making, and in recognition of inconsistencies in the outcome of such processes over time and in different contexts, a growing body of scholarship has sought to explore the political and procedural factors that shape decision-making in humanitarian programmes (Fuller, 2012; Le Pape, 2011: 248; Michael & Zwi, 2002). This pursuit is perceived as a desire to better make, justify, and defend choices, and to minimise moral discomfort. Such efforts are further bolstered by repeated sector-wide calls for greater accountability and transparency in the development and implementation of humanitarian programmes (Clarinval & Biller-Andorno, 2014).

While it is widely recognised that a degree of compromise is inevitable in humanitarian decision-making, and the broader practice of medical humanitarianism, the development of ethically informed and experientially derived frameworks with which to approach such issues is as of yet incomplete. In recognition of the humanitarian’s position as ‘moral entrepreneur’ (Brauman, 2012: 20), this paper draws from selected peer-reviewed publications, reports and presentations to situate current debates pertaining to humanitarian decision-making, compromise, and moral distress in medical humanitarian response.

The Humanitarian Predicament

The practice of humanitarian medicine is broadly characterised by the provision of immediate, yet often prolonged, assistance to crisis-affected populations. Given the scale, scope and dynamism of needs in such situations and the finite resources available to humanitarian organisations, staff are regularly pressed to make decisions related to both the allocation of resources at the project level, and the distribution of their programme of activities within a much broader national, regional and global spatial frame (Hunt, 2008; Calain & Schwartz, 2014). Additional contextual constraints such as suboptimal access, insecurity, and inadequate supporting infrastructure, and internal constraints such as shifting intra-organisational priorities, further complicate the ability to deliver medical humanitarian assistance.

Over the course of the last 45 years, Médecins Sans Frontières/Doctors Without Borders (MSF) has provided ‘emergency aid to people affected by armed conflict, epidemics, natural disasters and exclusion from healthcare’ (MSF, ND). Following MSF’s receipt of the Nobel Peace Prize in 1999, then MSF International President James Orbinski acknowledged the humanitarian’s responsibility to respond ‘wherever in the world there is manifest distress’. This core commitment is central to MSF’s Charter, and is often recited as a constitutive component of the humanitarian identity.

However, irrespective of the strength of the commitment to alleviating suffering, the impetus to assist populations in need is rarely commensurate with the financial, human, and other material resources available to fully realise this commitment in any given context (Michael & Zwi, 2002). As such, with very few exceptions difficult decision-making has become a defining feature of medical humanitarian response. De Waal captures this sentiment in his own analysis of ‘humanitarian’s tragedies’, when he describes the context in which humanitarianism is practised as ‘a world in which human ideals fail to match the realities of the human condition’ (2010: 130). Utilising a term first coined by Calabresi and Bobbitt, Heyse argues that the same discrepancy between the number of crisis-affected people worldwide, and the finite means with which to respond to their resultant needs, prompts humanitarian organisations to make ‘tragic choices’ (2013: 69–70).

In this respect, we can speak of the inevitability – though not necessarily an acceptance – of difficult decision-making, which in turn necessitates an exploration of the terms on which compromise is negotiated, and of its impact on those who are compromised. Such work inevitably derives from a growing body of research related to choices and decision-making (Fuller, 2006; Heyse, 2013), quality and standards of care (Brauman & Beck, 2017), and the principles and motivations that underpin medical humanitarian response (Rességuier, 2017; see Komenská, this volume).

The issue of compromise at the macro level – often reported in relation to access and negotiation, and the withdrawal of humanitarian activities – has been expounded elsewhere, and establishes an additional layer of complexity that cannot be overlooked in any comprehensive exploration of decision-making and compromise at the interpersonal – or micro – level. Nevertheless, authors have dedicated much effort to outlining such issues in other fora, and for the purpose of this paper, while reference is made in passing to macro-level issues, I simply signpost here some seminal comprehensive and empirically informed contributions (Rieff, 2002; Terry, 2002; Magone, Neuman & Weissman, 2012).

Multi-tiered Ethical Challenges

Existing research related to ethical issues in decision-making in humanitarian response can be broadly divided into three categories. The first encompasses literature that explores meta-level organisational decision-making processes (Heyse, 2013), with a focus on key themes su...

Table of contents

• Cover
• Praise for the book
• About the editors
• Title page
• Copyright
• Dedication
• Contents
• Acknowledgements
• Contributor Biographies
• Foreword: Humanitarian Action and Ethics
• Foreword: On the Front Lines of Humanitarian Medical Ethics
• Introduction
• 1. Difficult Decision-making, Compromise, and Moral Distress in Medical Humanitarian Response
• 2. Moral Entanglement and the Ethics of Closing Humanitarian Projects
• 3. The Outsider’s Role: Ethical Reflections from the Study of International–National Staff Relations in Development and Humanitarian Organisations
• 4. The Moral Motivation of Humanitarian Actors
• 5. Makeshift Humanitarians: Informal Humanitarian Aid Across European Close(d) Borders
• 6. Amateur Humanitarianism, Social Solidarity and ‘Volunteer Tourism’ in the EU Refugee ‘Crisis’
• 7. La Nouvelle France: Institutionalised Abuse, ‘Exception’ and Spectacle in the Exiled/Volunteer Relationship at the Franco–British Border
• 8. Ethical Challenges Among Humanitarian Organisations: Insights from the Response to the Syrian Conflict
• 9. Home and Away: Ethical Issues in Humanitarian Aid to Syrians in Israel
• 10. The Emergence of Humanitarian Failure: The Case of Haiti
• 11 Ethical Encounters as a Humanitarian Psychiatrist
• 12. One for All, or All for One: The Ethical Implications of Individual Human Rights-based and Public Good-based Frameworks in Emergency Mental Health
• 13. Ethics of Cultural Concepts and Conflicts Surrounding Disclosure of Gender-based Violence in Humanitarian Settings
• 14. The Invisible Man: The Shrouding of Ethical Issues Related to Sexual Violence Against Men in the Humanitarian Response in the Democratic Republic of Congo
• 15. Humanitarian Ethics in Médecins Sans Frontières/ Doctors Without Borders: Discussing Dilemmas and Mitigating Moral Distress
• 16. Stop Missing the Point: Managing Humanitarian Action Well
• 17. An Ethic of Refusal: The Political Economy of Humanitarianism Under Neoliberal Globalisation
• Afterword: The Ethics of Compiling a Book on
• About Zed