Ethical Decision-Making

in Humanitarian Health
in Situations of Extreme
Violence

Organizational Handbook

developed by
Johns Hopkins Bloomberg School of Public Health | Johns Hopkins University Berman Institute of
Bioethics | International Rescue Committee | Syrian American Medical Society
July 2019

center for public health and human rights

center for humanitarian health

XXXX

CONTENTS

I. INTRODUCTION .... .... .... .... ... .... .... .... 3

II. OVERVIEW OF THE PROJECT .... ... .... .... .... 4

A | Methods .... .... .... .... ... .... .... .... 4
B | Key Findings .... .... .... .... ... .... .... .... 5
C | Recommendations .... .... .... ... .... .... .... 6

III. IMPLEMENTING THE RECOMMENDATIONS .... ....

.... 8
A | Commit the Time and Resources to Address Ethical Issues .... 8
B | Articulate Ethical and Humanitarian Principles .... .... .... 9
C | Provide Regular Training and Support in Ethics to Staff . .... 14
 reate Process to Support Ethical Decision-Making .... .... 17
D | C
E | Provide Support for Mental Health and Psychosocial Needs of Staff 21

IV. ANNEXES .... .... ....

.... ... .... .... .... 23
A | Scenarios .... .... ....
.... ... .... .... .... 23
B | Ethical Decision-Making Worksheets. ... .... .... .... 27
C | References and Resources .... .... ... .... .... .... 34

V. ACKNOWLEDGEMENTS .... .... ... .... .... .... 35

Illustrations

Table 1 .... .... .... .... .... ... .... .... .... 12
Table 2 .... .... .... .... .... ... .... .... .... 15
Figure .... .... .... .... .... ... .... .... .... 16

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 I. INTRODUCTION

Humanitarian health organizations face enormous The handbook is organized so that, following this
ethical challenges in conducting their operations, introduction, the second section presents a brief
particularly in situations of severe and persistent overview of the JHU/IRC/SAMS project on ethical
violence. We define ethical challenges broadly here challenges in humanitarian health in situations
to include situations where the best moral course of extreme violence. This overview describes the
of action could be unclear (e.g., when additional methods of our study, and presents key findings
deliberation or analysis is necessary to define the from our systematic literature review, results
right action), where it might not be possible to fully from our interviews with organizational managers
uphold all the moral values at stake (e.g., when a and front-line health workers, and a summary
duty to avoid harm conflicts with the duty to serve of discussions held in Gaziantep, Turkey and
all equally), where the moral course of action is clear Amman, Jordan with organizations working on the
but circumstances prevent one from taking it, or humanitarian health response in Syria. The overview
where there is no right answer but action is needed. also presents the five key recommendations from
the project, integrating results from the literature
This project and this organizational handbook review, the interviews, and the workshops. These
are the result of a collaboration by the Center for five recommendations (see below) are described in
Public Health and Human Rights and the Center further detail in the third section, with a focus on how
for Humanitarian Health at the Johns Hopkins organizations might take steps to implement them.
Bloomberg School of Public Health, supported
by individuals from the Johns Hopkins University In the annexes, the handbook provides examples
Berman Institute of Bioethics, the Syrian American of four scenarios of ethical challenges that
Medical Society (SAMS) and the International organizations might wish to use as part of their
Rescue Committee (IRC). The project explored the trainings on ethics and ethical decision-making. We
ethical challenges organizations faced in situations also provide a series of worksheets for organizations
of extreme violence in Syria, and, working from to use in processing their ethical decision-making.
that context, sought to provide a framework of We also provide a list of references and resources for
principles for ethical decision-making, as well as a further review.
handbook with practical guidance for humanitarian
health organizations to resolve these complex
ethical challenges.

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II. O
 VERVIEW OF THE community views be taken into account? In these
circumstances, moreover, front-line health workers
PROJECT may experience severe psychological impacts as
well as moral distress, which occurs when someone
knows what the ethically right action is, but because
of constraints imposed, that action cannot be taken.

Although the research focused on Syria, we hope

that the recommendations that flow from the
This project explored the ethical challenges project may be useful in other violent contexts
humanitarian health organizations face in situations where humanitarian organizations work.
of extreme violence against civilians, particularly
when healthcare facilities and personnel become
targets in the conflict. Its objective was to provide A | methods
processes and mechanisms as well as practical
tools to guide humanitarian health organizations We conducted a systematic literature review
through complex ethical challenges facing them to understand the range of ethical challenges in
in these settings.1 humanitarian health practice in conflict settings
and the approach taken to their resolution, as
The project originated as a result of the challenges described in peer-reviewed literature. We conducted
international and local non-governmental interviews with 41 managers working in Turkey
organizations (NGOs) and front-line health workers and Jordan engaged in supporting organizations
face as a result of violence inflicted on hospitals and operating in Syria and 58 frontline health workers
health workers in Syria. At times, individuals in these in northwestern and southern Syria to learn about
settings must forgo compliance with core ethical the challenges individuals and organizations
commitments, choose to comply with one ethical faced in providing health care, their perceptions
obligation at the expense of another, or to take an of the ethical dimensions of those challenges,
action where no obviously right action exists. how they sought to address the challenges, and
how the violence affected their well-being. We
For example, when a hospital is attacked and cannot then held two rounds of workshops in Amman
continue operations, is it better to rebuild at the (Jordan) and Gaziantep (Turkey). In the first round
same location or move to a safer facility farther of workshops (held in 2018), health program staff
away? Rebuilding in the same location might invite from various international and non-governmental
further attacks while moving the facility farther organizations met to review the findings of the
away may hinder access to health care for some literature review, the interviews, and two proposed
individuals and communities How should different decision-making tools for addressing ethical

1 This overview is taken from the Executive Summary of a more extensive project report, Johns Hopkins Bloomberg School
of Public Health, International Rescue Committee, Syrian American Medical Society. Reality makes our decisions: ethical
challenges in humanitarian health in situations of extreme violence: report and recommendations. 2019.
http://hopkinshumanitarianhealth.org/assets/documents/LR_XViolenceReport_2019_final.pdf.
2 One of the tools is described in: Clarinval C, Biller-Andorno N. Challenging operations: an ethical framework to assist
humanitarian aid workers in their decision-making processes. PLOS Currents Disasters 2014, edition 1.
The other is described in: Fraser V, Hunt MR, De Laat S, Schwartz L. The development of a Humanitarian Health Ethics Analysis
Tool. Prehosp Disaster Med 2015; 30: 412–20. See also: Fraser V, Hunt MR, Schwartz L, De Laat S. Humanitarian Health Ethics
Analysis Tool: HHEAT handbook. 2014. https://humanitarianhealthethics.net. Both of these tools are discussed in more detail
in later chapters.

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 OVERVIEW OF THE PROJECT

challenges in humanitarian health practice.2 Limitations of resources: Staff shortages, lack

Participants discussed practical recommendations of qualified staff, and not enough bed capacity,
and implementation steps to address the ethical medication, or equipment in facilities created
challenges. In the second round of workshops challenges about who should get care and who
(held in 2019) participants (many from the should provide care under what standard of quality.
same organizations that participated in the first To some extent, over time, skills training helped
round of workshops) m et to review final project address the problem of staff engaged in medical
recommendations and to review and comment on practice beyond their training after a bombardment.
drafts of this organizational handbook. Traditional principles of triage were strained. Trauma
care sometimes was provided at the expense of
primary care.
B | key findings
Access restrictions: Border closings and travel
1. literature review restrictions, as well as Syrian government
restrictions, limited the ability to provide supplies
The most frequently reported ethical challenges and medications in parts of Syria, especially in
identified in an in-depth analysis of 66 articles besieged areas. Some interviewees noted that
from a group of 2,077 potentially relevant hospitals near the Turkish border in northwestern
publications related to providing the highest Syria were better equipped and more able to
attainable quality of care, properly managing assets, attract and retain higher qualified staff than
and protecting and caring for health workers in locations subjected to bombing. While this strategy
conflict settings. The humanitarian principle most increased access to care for many, it resulted in
frequently noted as challenging to uphold was problems of equity for populations who could not
neutrality, followed by independence, humanity, access these facilities.
and impartiality. We found important areas overlap
and reinforcement, as well as tension, between Constraints on care imposed by other actors:
ethical and humanitarian principles in the literature Without exception, front-line health workers
(humanitarian principles are discussed in more detail and site managers expressed a commitment to
in the chapters that follow). the principle of impartiality in care and to hiring
based on merit and professional qualifications.
 anager and front-line worker
2. m Armed groups, however, sometimes demanded
interviews priority in treatment or preferential hiring,
employing verbal threats, harassment, and
The effects of targeted attacks: Front-line health humiliation as means of coercion. Sometimes
workers accepted the risks of choosing to remain donor funding restrictions and accountability
in Syria to provide care, often expressing a strong standards could limit service provision.
sense of moral duty to their country and fellow
citizens. They confronted many difficult decisions, Challenges in making difficult medical and
for example whether to close down facilities or operational decisions: Organizations running or
pause services after attacks or limit the length of supporting health facilities and personnel from
patient stays, which could potentially compromise outside Syria provided material and financial
the health status of patients. Relocating facilities support, but some front-line health workers found
underground or to new communities sometimes that support too limited. Remote management staff
created tensions with people in communities who were often too far removed from operations to be
were concerned that the presence of a hospital able to advise in real-time. Additionally, they often
made them more vulnerable to attack. lacked comprehensive policies to address critical

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OVERVIEW OF THE PROJECT

and emergent issues with ethical implications, such as Respondents expressed a sense that the current
relocating facilities, pausing or re-instating services, circumstances left them no choice but to stay
transitioning to routine health services, triaging in Syria and help but were also aware that their
and prioritizing patients, coping with high volumes decisions deeply affected their families, yet another
of trauma cases, managing under-qualified staff, cause of psychological distress.
addressing staff turn-over and burn-out, providing
psychological supports to staff, involving local 3. practitioner workshops
communities in decision-making, and advising on
negotiations with military or paramilitary groups. Workshop participants emphasized that the most
difficult ethical challenges they have faced are
While these gaps gave front-line health workers a a product of violations of the laws of war that
certain degree of freedom and independence, it also would best be ameliorated or avoided by securing
placed pressure on them at critical times. Front-line compliance with the laws. Participants believed
health workers also reported that organizations that there was a need for more systematic discussion
paid salaries lacked policies on compensating families of ethics in their organizations, including guidance
in the event they were killed in an attack. Women on how to use these principles to address real-
respondents noted that organizational support for world challenges, e.g., specifying principles at stake,
addressing gender discrimination—in terms of hiring identifying ways to balance harms and benefits
policies and treatment of staff—was often lacking. of a particular course of action, and finding ways
of mitigating harms. Consensus existed on the
The toll on the mental health of healthcare workers: importance of creation of structures and processes
health workers faced significant psychological for addressing ethical challenges and use of
burdens and distress resulting from working long decision-making tools, organization-wide training,
hours under the strains of these conditions. Many and engaging communities.
respondents described moral distress in having
to make wrenching life-and-death decisions,
including determining priority cases based on C | recommendations
resources available, while feeling that they were
falling short of their commitment to ethics and the The recommendations are directed at organizations
principle of humanity. and agencies providing direct health services, as

Recommendations

1. C
 ommit time and resources to addressing key 4. Create processes and mechanisms within
ethical issues faced by the organization and the organization to support ethical
the health professionals it supports. decision-making and recording and
disseminating the decisions.
2. Articulate clear ethical and humanitarian
principles as a foundation to address the 5. Provide support for the mental health and
challenges they face. psychosocial needs of staff and others
supported by the organization.
3. P
 rovide regular training and support in ethics
to staff within the organization.

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 OVERVIEW OF THE PROJECT

well as to organizations such as local or international While the recommendations are directed at
NGOs, donors, or UN agencies that support those humanitarian health organizations, we emphasize the
providing direct services. They recommend both a important responsibility that donors have in providing
set of ethical and humanitarian principles on which support to organizations in order to carry them out.
to ground decisions and steps that organizations can In the following sections, we address each of these
take to address the challenges in a systematic and recommendations, focusing on the action steps that
structured way. The recommendations are intended an organization should take to implement them.
to address issues at different levels of operations,
from headquarters, to regional offices, to the frontline
operations in conflict zones.

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III. I MPLEMENTING THE should have some formal training in ethics, or

access to people who have such a background.
RECOMMENDATIONS What is essential is that someone with experience
and basic understanding of ethics as well as
programming is available for multiple purposes:
first, helping organizations articulate their ethical
and humanitarian principles and train staff on
these; second, providing (or identifying) additional
expertise where needed; third, coordinating the
 ommit time and resources to
A | c process of making and documenting decisions,
address ethical issues processing and evaluating impacts; and fourth,
sharing results. Some of these steps might be
In the process of organizational ethical decision- accomplished in a few days while others should
making, we recommend that organizations make extend through the duration of an organization’s
a clear commitment to the process, including involvement in a particular intervention or crisis
developing internal mechanisms and allocating response. An individual in this position must have
the necessary resources—human, financial, the support of and access to senior management
and material—to carry it through. Organizations and sufficient authority to lead the process.
should have a focal point, such as an individual or
committee, to oversee and implement the process Organizations may also benefit by establishing
of reviewing ethical challenges, making a decision, a committee or working group to coordinate
recording the decision and sharing both the response to ethical challenges. The entity could
decision, and the outcomes, within the organization. be composed of a group of managers, and,
preferably, with representation by front-line health
A 2016 report by Katherine Haver noted that while workers as well. The group should meet regularly
many international organizations are adopting a and convene as well in response to the need to
risk management approach to inform decision- make critical decisions. As with individuals tasked
making in high-risk environments, “ethical risks… with overseeing decisions on ethical questions,
are generally not included as a category, and the committee or working group should have the
are instead enumerated under ‘operational’ or support of and access to senior management. In
‘reputational’ risks, if they are included at all. In addition to supporting the idea of having a trained
practice, this has meant that they are often left out.”3 ethicist facilitate these processes, Clarinval and
Organizations working in contexts of severe violence Biller-Andorno also suggest that initial discussions
must incorporate responsibility and processes should evolve into regular meetings.
for addressing ethical risks, and ethical decision-
making, into their organizational management. In establishing these structures and committing
resources, we encourage organizations to consider
Organizations can designate a manager or other a comment from the Humanitarian Health Ethics
staff member as a focal point for coordinating Analysis Tool (HHEAT Tool) that “the middle of
decision-making on ethical challenges. The person an acute crisis might not be the ideal time for

3 Haver K. Tug of war: Ethical decision-making to enable humanitarian access in high-risk environments. Humanitarian Practice
Network (HPN). Overseas Development Institute, London, 2016. https://odihpn.org/wp-content/uploads/2016/10/NP80-web-
string.pdf. See also: Stoddard A, Haver K, Czwarno M. NGO risk management: principles and promising practice. Humanitarian
Outcomes and InterAction. 2016. https://www.humanitarianoutcomes.org/publications/ngo-risk-management-principles-
and-promising-practice.

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 IMPLEMENTING THE RECOMMENDATIONS

thoughtful ethical discussion and reflection.”4 This One way of viewing ethics relates to three basic
underscores the importance of planning for and activities:
implementing decision-making processes that will
be needed in the heat of a crisis. The optimal time →→ D
 efining the principles and obligations that direct
to plan for and to implement this is at the start of right & wrong actions
a particular project or intervention. This can be
supplemented by periodic adjustments, in-service →→ W
 eighing those principles and obligations when
reviews and by after-action reporting, evaluation, they conflict or suggest different actions
and sharing of results.
→→ Determining a process by which decisions get
made, including evaluation of whether it was the
 rticulate ethical and
B | a “best” decision.5
humanitarian principles
Thus, ethics is not simply a “feeling” (our feelings
We recommend that organizational staff-members can help identify ethical issues, but feelings can
(and, if relevant, key stakeholders including local be misguided or wrong). Ethics is not only about
partner organizations) articulate their ethical “dilemmas”, where there is no right answer; ethics
obligations and humanitarian principles. To assist can also be about doing what we do, but doing it
in this step, we first provide some background better. Finally, ethics is not the same as saying that
information on ethics and humanitarian principles a person is “good” or “bad” though there may be an
and how, in our literature review, ethical obligations element of moral valuation involved.
and humanitarian principles map together in the
context of ethical challenges faced by humanitarian In clinical ethics, core ethical principles include
health organizations. respect for persons (including respect for human
dignity and respect for individuals’ autonomous
1. ethics choices), beneficence (the promotion of others’
well-being), non-maleficence (“do no harm”), and
To the extent that decisions about right action in a justice (both in terms of fair distribution of resources
particular circumstance involve determining what and fair processes for decision-making). These
is best, what is most appropriate, what should be principles, which have been widely embraced in
done, who is responsible, and so on, those decisions clinical care and research settings, can be adapted
involve ethics. Ethics has, at its core, the systematic to the provision of health care to communities, even
study of the fundamental values and norms that though how the principles are weighed and applied
help individuals, organizations, and societies might differ in different settings. They focus on
determine what ought to be done, including what producing benefits, avoiding and preventing harms,
ought to be done when values and norms may be in producing the maximal balance of benefits over
tension, perhaps irresolvably so. Ethical questions harms and other costs, and distributing benefits
rarely have straightforward answers, and requires and burdens fairly and ensuring and building and
consideration of more than logistics, operational maintaining trust.6
analysis, and situational analyses.

4 Fraser V, Hunt MR, Schwartz L, De Laat S. Humanitarian Health Ethics Analysis Tool: HHEAT handbook. 2014, p. 12.
https://humanitarianhealthethics.net.
5 See: DeCamp M. Ethics and humanitarian principles. https://auth.voicethread.com/myvoice/thread/11002963/64425964/
61641932.

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IMPLEMENTING THE RECOMMENDATIONS

2. humanitarian principles including four main components: “(1.) human

rights objectivity and the pursuit of justice…
Humanitarian principles are a second source of (2.) consultation with and accountability to the
values and norms that can animate the actions people with whom solidarity is expressed. (3.) Shared
of humanitarian organizations. These are moral risk and suffering with the people. (4.) Concrete
and operational principles that humanitarian action in support of the people and their cause.”8
organizations have widely embraced and which
have been adopted by the UN and its humanitarian For purposes of our project, and this handbook,
agencies and include humanity, neutrality, we have adopted the principalist approach,
impartiality, and independence.7 These are which focuses on standards or rules for conduct
defined as: and is widely accepted in the humanitarian
community and reflected in professional codes and
Humanity: Human suffering must be addressed international standards of practice. For example,
wherever it is found. The purpose of humanitarian the SPHERE Humanitarian Charter9 emphasizes
action is to protect life and health and ensure acting in accordance with the principles such as
respect for human beings. humanity, impartiality, non-discrimination, the
right to protection and security, and the right to
Neutrality: Humanitarian actors must not take sides receive humanitarian assistance. The International
in hostilities or engage in controversies of a political, Red Cross and Red Crescent Code of Conduct
racial, religious or ideological nature. includes seven principles: humanity, impartiality,
neutrality, independence, voluntary service, unity,
Impartiality: Humanitarian action must be carried and universality.10
out on the basis of need alone, giving priority to
the most urgent cases of distress and making no Just as with ethical obligations, humanitarian
distinctions on the basis of nationality, race, gender, principles can come in conflict with one another
religious belief, class or political opinions. and with ethical principles, though there is also
overlap between the two. The principle of justice,
Independence: Humanitarian action must be for example, to treat all people equally and fairly,
autonomous from the political, economic, military overlaps with the principle of impartiality, to render
or other objectives that any actor may hold with decisions without giving preference to race, gender,
regard to areas where humanitarian action is being religious belief, political affiliation, etc.
implemented.
At a high level, humanitarian principles and ethical
Recently there has been discussion of a fifth obligations are essentially normative statements
principle, solidarity. This has been defined as about what should be done. Yet these two areas

6 See: Childress J, Foden R, Gaare D, et al. Public health ethics: mapping the terrain. J Law Med Ethics 2002; 30: 170–78.
7 UN Office of Coordination of Humanitarian Affairs. What are humanitarian principles? https://www.unocha.org/sites/dms/
Documents/OOM-humanitarianprinciples_eng_June12.pdf. See also: UN General Assembly Resolution 47/182 (1991) and UN
General Assembly Resolution 58/114 (2004).
8 See: Slim H. Relief agencies and moral standing in war: principles of humanity, neutrality, impartiality and solidarity. Dev Pract
1997; 7: 342–52.
9 SPHERE Project. The humanitarian charter. https://www.spherestandards.org/wp-content/uploads/2018/07/the-
humanitarian-charter.pdf.
10 International Red Cross and Red Crescent Movement. Code of conduct for the International Red Cross and Red Crescent
Movement and Non-Governmental Organizations (NGOs) in disaster relief. https://www.icrc.org/en/doc/assets/files/
publications/icrc-002-1067.pdf.

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 IMPLEMENTING THE RECOMMENDATIONS

of scholarship do not always intersect, and organizational ethical obligations and humanitarian
organizations may view and use them differently. principles could be undertaken within the
As the section below discusses further, bringing CHS framework.
together ethical obligations and humanitarian
principles has relative advantages: humanitarian Mapping the findings from the literature review
principles, on the one hand, may provide more with the results from the interviews with
clear substantive guidance by offering ideal organizational managers and front-line health
standards for humanitarian action, while ethics, workers, we found that we could also begin to
on the other hand, may be better at defining map the eight ethical obligations with the five
a decision process to deal with challenges and humanitarian principles and identify overlapping
tensions that arise. challenges (see Table 1, pages 12–13). We should
note that the literature review showed overlap
 apping ethical and humanitarian
3. m between ethical obligations and humanitarian
principles principles beyond those included in the table.
The table lists only the main corresponding
In our review of the literature, we identified 8 major humanitarian principle mapped to a corresponding
ethical obligations that have been challenging to ethical obligation. We also note that the principles
fulfill in Syria and may well be applicable to other can align in some circumstances but not others;
settings of extreme violence. These were: for example, seeking to maintain neutrality may not
advance beneficence in all circumstances.
→→ Providing the highest attainable quality of care
→→ Protecting workers  rticulating organizational
4. a
→→ Minimizing (unintentional) harms of relief work principles and values
→→ Supporting a locally led response
→→ Organizational resource management (obtaining, Table 1 maps five humanitarian principles with eight
using, and maintaining resources) ethical obligations and then further maps some
→→ Distributing benefits and burdens fairly overlaps of these principles and obligations with
→→ Honest and transparent communication particular challenges identified by our respondents
→→ Incorporating local knowledge and norms working in Syria. We recommend that organizations
undertake a similar exercise for themselves. This
Several of these eight ethical obligations, it should exercise can begin with the humanitarian principles
be noted, align with the Core Humanitarian Standard and ethical obligations we have identified, but also
on Quality and Accountability (CHS Alliance, 2014), include in the mapping other obligations, principles,
Nine Commitments, including that “communities and values as well as the challenges they face and,
and people affected by crisis…receive assistance perhaps, the kinds of strategies they have identified
appropriate to their needs; have access to the to address these challenges.
humanitarian assistance they need at the right time;
are not negatively affected and are more prepared, Organizations should also articulate the key values
resilient and less at-risk as a result of humanitarian that drive and sustain their mission. These may be
action;…[and] can expect that the organizations documented in the form of a mission statement,
assisting them are managing resources effectively, statement of organizational values, or a charter.
efficiently and ethically.” Médecins Sans Frontières/Doctors Without
Borders (MSF), for example, defines its mission as
Given that many humanitarian organizations “to provide lifesaving medical care to those most
already have processes in place to ensure that in need” and ask all MSF members to honor the
these commitments are met, the articulation of following principles:

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ETHICAL PRINCIPLE; ETHICAL EXAMPLES OF CHALLENGES IN HUMANITARIAN
HUMANITARIAN OBLIGATION SETTINGS OF EXTREME VIOLENCE
PRINCIPLES

Respect for persons; Incorporation of →→ Different, competing factions/groups make it

Humanity local knowledge difficult to determine who legitimately represents
and recognition local norms and knowledge
of cultural →→ The community may not take account of the need to
norms serve all people
→→ Cultural norms may devalue women or others

Honesty and →→ Potential security risks in transparency regarding the

transparency in location of hospitals
communication
and interactions

Beneficence (and Provide Access and quality compromised by:

non-maleficence); the highest →→ Violent attacks and interference
Humanity attainable →→ Disruption or shortage of medical supplies,
[Neutrality] quality of care personnel, electricity
and services →→ Difficulties getting medicine and providers to
front-line communities
→→ Because of shortages, health workers engaged in
practice beyond their training
→→ Patients cannot access services (distance, insecurity)
→→ Essential health services, e.g., primary care, not
offered as trauma care is a priority
→→ Early discharge or inappropriate procedures because
of fear of attack
→→ Difficulty of implementing accountability
mechanisms to ensure quality because of security,
communication or access issues
→→ Coercion by parties to conflict to favor certain
patients or refrain from providing services to others
→→ Political allegiances of providers

Minimize harms →→ Closing/moving a hospital inevitably creates harm,

of response but difficult to assess options that creates least harm
→→ Keeping health facility open could lead to
vulnerability to attack
→→ Lack of fully qualified staff risks harm to patients
→→ Triage and other health priorities inevitably hurt
those who could be treated

Protect and care →→ Organization cannot reasonably assure the safety of

for workers health workers in the field, and transfers risk to them
→→ Organization has difficulty addressing the psycho-
social needs of health workers
→→ Contingency, safety, or emergency plans difficult
→→ Violence against and devaluation of women and
vulnerable groups
→→ Health workers’ families may not be compensated if
the health worker is killed
 ETHICAL PRINCIPLE; ETHICAL EXAMPLES OF CHALLENGES IN HUMANITARIAN
HUMANITARIAN OBLIGATION SETTINGS OF EXTREME VIOLENCE
PRINCIPLES

Justice (procedural); Support a →→ Difficulty in identifying a local leader or partner

Humanity, locally-led →→ Competing groups claim to represent the local
Independence response response
[Neutrality] →→ Local actors may engage in corruption,
mismanagement, or lack adherence to ethical and
humanitarian values

Justice (distributive); Distribute →→ Primary and chronic disease care subordinated to

Impartiality/ benefits and trauma care
Independence burdens →→ Health workers may receive priority in treatment
equitably →→ Violence or threats interfere with impartial care
→→ Security conditions render it difficult to reach people
equally
→→ Donors favor a particular program or group
→→ Triage based on survival not need
→→ Insecurity prevents reaching those in need
→→ Parties to conflict coerce decisions
→→ Violence prevents facilities and staff from operating
independently
→→ Donors impose requirements inconsistent with
organizational judgments about equity

Appropriate →→ Insecurity makes it difficult to secure, protect and

acquisition and account for assets
management of →→ Corruption and bribe-seeking make it difficult to
assets manage assets appropriately
→→ Donors impose requirements that cannot be fulfilled
→→ Insecurity makes it difficult to recruit and retain
personnel
→→ Institutional or personal favoritism undermines hiring
personnel

Table 1: Ethical and humanitarian obligations and challenges

→→ M
 SF provides assistance to populations in humanitarian assistance. MSF claims full
distress, to victims of natural or man-made and unhindered freedom in the exercise of
disasters, and to victims of armed conflict. They its functions.
do so irrespective of gender, race, religion, creed,
or political convictions. →→ M
 embers undertake to respect their professional
code of ethics and to maintain complete
→→ M
 SF observes neutrality and impartiality in the independence from all political, economic, or
name of universal medical ethics and the right to religious powers.11

11 Médecins Sans Frontières/Doctors Without Borders. Who we are > Principles > Charter. https://www.doctorswithoutborders.
org/who-we-are/principles/charter.

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IMPLEMENTING THE RECOMMENDATIONS

Clarinval and Biller-Andorno present a table derived organization, and among local operational
from a study of 46 international humanitarian partners. This should include training on core
organizations in which they found that the ten most ethics and humanitarian principles, an
frequently mentioned values include some that were introduction to ethical decision-making processes,
not addressed in our literature review, including and tailored instruction in the unique historical
poverty reduction, accountability, sustainability, and cultural context—and previous experiences
transparency, relief, dignity, and empowerment. They working in that context—at the site(s) where the
organized these values by specific and organization operates.
cross-cutting values and disaggregated by macro and
meso level (headquarter and regional level) and micro There are a wide variety of resources—in print and
(local) level.12 online—that provide materials on humanitarian
principles, humanitarian ethics, and humanitarian
How these organizational values are organized does standards (See Annex B). We do not attempt to
not need to follow any particular table or approach. describe all of these, nor do we suggest that this
Whatever the approach, however, we do recommend handbook should replace any of them; rather,
that the ethical and humanitarian obligations and we encourage all organizations to decide for
the organization’s additional values be articulated at themselves as to what materials work best for
the various operational and decision-making levels their purposes in a given context. That said, the
that are relevant either to the organization as a materials in this handbook—supplemented by
whole or to the project or intervention for which the other resource materials, some of which are to be
ethical decision-making will apply. In our interviews, found References and Resources section in the
we found it was fairly common that organizational annexes—provide a structure for training on both
values and priorities did not always align across humanitarian principles and ethical obligations,
different levels of decision-making. Indeed, it was specifically within the context of situations of
sometimes within organizations, and between or extreme violence.
among organizational levels, where ethical challenges
presented themselves in terms of competing, or  ools for ethical decision-making
1. t
unclear, principles and priorities guiding decision- in humanitarian contexts: two
making. Given that, the articulation of organizational examples
values and principles should involve a process
of exploring these values across many different Among the many resources that organizations may
organizational levels and locations, then documenting wish to consider are the Clarinval/Biller-Andorno
and sharing the mission statements that result. ethical framework to assist humanitarian aid
workers in their decision-making approach and the
Humanitarian Health Ethics Analysis Tool (HHEAT)
 rovide regular training and
C | p handbook.13 Each of these tools describes a process
support in ethics to staff for humanitarian organizations to address ethical
challenges in a systematic, step-wise approach; both
We recommend that organizations provide regular encourage group discussion and collaboration in
training and support in ethics to staff within their making decisions on difficult ethical challenges.14

12 Clarinval C, Biller-Andorno N. Challenging operations: an ethical framework to assist humanitarian aid workers in their decision-
making processes. PLOS Currents Disasters 2014. doi: 10.1371/currents.dis.96bec99f13800a8059bb5b5a82028bbf.
13 Ibid. See also: Fraser V, Hunt, MR, De Laat S, Schwartz L. The development of a humanitarian health ethics analysis tool.
Prehosp Disaster Med 2015; 30: 412–20. And: Fraser V, Hunt MR, Schwartz L, De Laat S. Humanitarian Health Ethics Analysis
Tool: HHEAT handbook. 2014. https://humanitarianhealthethics.net.

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 IMPLEMENTING THE RECOMMENDATIONS

Although neither tool was created explicitly for approach taken by Clarinval and Biller-Andorno in
the purpose of ethical decision-making in settings developing their ethical framework involved three
of extreme violence, their focus on humanitarian elements: The first was to suggest a set of normative
action provide a helpful framework and formed the values, drawing upon both public health ethics and
basis for development of the processes presented clinical ethics, and described at the macro, meso,
in this manual. These tools do not define correct and micro level. These include both “substantive”
answers for particular ethical questions but instead and “procedural” values, as well as “specific” and
set out a process for ensuring that relevant ethical “cross-cutting” values. At the micro (local) level, for
considerations and factors are considered in example, specific substantive values could include
the decision, and that the process of decision is focus on the worst off, beneficiary-centeredness,
systematic and clear. Each of the tools is designed and non-discrimination; specific procedural
to help decision-makers assess the values at stake, values could include responsiveness, protecting
the facts and circumstances that make it difficult to confidentiality and effectiveness. Substantive cross-
adhere to all the values, assess harms from various cutting values at the micro level could include duty
courses of action, and then arrive at a rational, if to provide care, justice, solidarity, and beneficence,
sometimes difficult, decision. and cross-cutting procedural values could include
transparency and scrutiny. The second element is a
Clarinval/Biller-Andorno ethical framework for ten-step approach to ethical decision-making (see
decision-making by humanitarian workers. The Table 2). The third element involved institutional

10 STEP PROCEDURAL PROCESS DESCRIPTION

1. Gather evidence What are the facts? And who is affected?

2. State the ethical values and principles What ethical and humanitarian principles are
involved?
3. Examine arguments State clearly what the ethical tension is

4. Define options What decisions could you make?

5. Weigh the options What are the advantages and disadvantages of

each option?
6. Elaborate decision Make your decision

7. Justify the decision State why you made that decision

8. Implement the decision

9. Monitor and evaluate the outcome How will you know if your decision was correct?
(Indicators and metrics)
10. Make recommendations for future actions Can you prevent this from happening in the
future?

Table 2: Ten-step approach to ethical decision-making in humanitarian aid

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IMPLEMENTING THE RECOMMENDATIONS

commitments and requirements to maintain high Humanitarian Health Ethics Analysis Tool
ethical standards. Their recommendation, coming (HHEAT). The Humanitarian Health Ethics Analysis
from a clinical ethics framework, suggested a “hub Tool (HHEAT) offers a six-step, rather than ten-step,
and spokes” model in which a trained ethicist approach to ethical analysis and decision-making
acts as the “hub” for the various activities an in humanitarian contexts, though it has many of
organization will need, including defining values, the same elements as the Clarinval/Biller-Andorno
developing the structures and processes needed framework. The steps in the HHEAT process
for implementing the ten-steps approach, and (summarized in the figure below) are as follows:
evaluating institutional results.

HHEAT: Humanitarian Health Ethics Analysis Tool

1. Identify/Clarify Ethical Issue Is it really an ethical issue? What is at stake and

What is at stake and for whom? for whom? How is the issue perceived from
different perspectives? When must a decision be
made? Who is responsible for making it? What
has been done so far?

2. G
 ather Information What information is needed to deliberate
What do we need to know to assess the issue? well about this issue and enable us to make a
well-­considered decision? What constraints to
information gathering exist? Consider:
(a) Resource Allocation and Clinical Features
(b) Participation, Perspectives and Power
(c) Community, Projects and Policies

3. R
 eview Ethical Issue Does the process so far reveal new aspects
Does information gathered lead us to of the ethical issue or suggest the need to
reformulate the issue? reformulate or redefine the issue? Have our
biases/interests affected how we see the issue?

4. E
 xplore Ethics Resources What values and norms ought to inform our
What can help us make a decision? decision making? Consider: professional moral
norms and guidelines for healthcare practice;
human rights and international law; ethical
theory; local norms, values and customs.

5. E
 valuate & Select the Best Option What options are possible in this situation and
What options are possible and which is the what ethical values support each option? What
“best” under the circumstances? consequences might result from each option?
Can consequences, values and obligations be
reconciled?

6. F
 ollow-­Up What can we learn from this situation? What
What can we learn from this situation and support do those involved need?
what supports are needed?

www.humanitarianhealthethics.net
 IMPLEMENTING THE RECOMMENDATIONS

 cenarios and case studies

2. s commitment but establishment of organizational
structures to ensure that ethics is built into staff
Scenarios and case studies are well established training, operational decision-making, and program
as effective training approaches, and are utilized evaluation. Organizations should clarify what
by, among many others, Clarinval and Biller- processes staff members should participate in for
Andorno. Their case studies examine issues at the documenting the decisions they make that involves
macro-level (headquarters), meso-level (country/ an ethical challenge, including how the decision
region), and micro-level (beneficiary level) in a was made, who was involved, what were the
non-specific humanitarian context. In the annexes outcomes and impacts (positive or negative), what
of the handbook are four scenarios adapted from recommendations should be made for future action,
interviews done with organizational managers and and how to share these results within and outside
front-line health workers in Syria. These focus on: the organization.
hospital closures (deciding when/if to close or move
a facility following repeated attacks; impartiality Often, there is also a critical need to make joint
(dealing with threats and intrusive demands for decisions or consult across multiple organizations
health care by armed groups); quality of services and/or multiple locations. Thus, there should be
(dealing with staff shortages, task-shifting, and consultations between local headquarters and field
inability to effectively treat or save patients); and operations including where remote management is
psychosocial needs and support (supporting and involved; between supporting NGOs and front-line
treating health workers and other staff traumatized groups e.g., health directorates; and between and
by their experiences and working conditions). among NGOs that work together in a facility.

Processing these scenarios using the approach  ake and document decisions that
1. m
outlined in Annex A, Section IV below in small groups involve ethical challenges
first and then discussing the implications for the
organization provides a means for identifying how In making organizational decisions that involve (or
specific ethical challenges might be processed, what might involve) ethical challenges, organizations can
principles were at stake and what kind of consultation decide which decision-making tool best fits their
or decision-making process might be important for needs. Based on feedback from practitioners in the
most effectively addressing these challenges. project workshops, and drawing from the HHEAT
Tool and Clarinval/Biller-Andorno framework, we
suggest five steps in making, documenting, and
 reate processes and
D | c distributing decisions and in the next section address
mechanisms to support ethical evaluation. We provide templates for processing
decision-making these questions, documenting the answers and
sharing the results of the discussion, within the
We recommend that organizations create organization and more broadly. The steps are:
processes and mechanisms to support ethical
decision-making and recording and disseminating →→ Identify and clarify the initial question and ethical
the decisions. This includes creating easily issue.
accessible structures to facilitate, record and →→ Gather additional information.
disseminate decisions; adopting decision-making →→ Review the ethical issue in light of the information
tools for addressing ethical challenges; and gathered.
engaging with collaborating organizations to →→ Generate, define, evaluate options.
evaluate and share results. Ethics is a discipline in →→ Select an option, then make and document the
itself and, as such, requires not only organizational decision, and share it.

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IMPLEMENTING THE RECOMMENDATIONS

We note that similar questions appear at different To facilitate implementation and documentation of
stages in the process, as more information is these steps, we have provided printable tables in
gathered, more consultation is conducted, and more the annexes.
deliberation takes place (see Panels 1–5).

(1.) Identify and clarify the initial question and ethical issue

(a.) What decision must be made? What are the ethical and humanitarian obligations and organizational
values at stake in making it? What frameworks—organizational or more general—are you using to answer
this question? Are there conflicts between/among the values and obligations surrounding the question?
Record the results of the initial assessment.

(b.) Does this decision involve a choice between multiple “goods” or between multiple “bads” or between
different “goods” and “bads”? Might each choice result in a benefit, but the benefit of each can’t be realized
by the other choice; might any decision made result in harm? Record the results of the assessment.

(c.) Could the result of a potential decision be damaging to someone or to some group? If so, who are those
individuals or groups? (be careful if sharing these documents beyond a limited number of people directly
involved in the issue, so as not to disclose personally identifiable information or other sensitive details).
Record the results of the assessment.

(d.) Is the right decision apparent, but cannot be implemented due to features of the situation? If yes,
describe these constraining features.

(2.) Gather additional information

(a.) What are the likely consequences of various decisions/options as to who is affected and what the effects
are? Record what the consequences are and to whom.

(b.) Look more deeply at information on who is harmed if a decision goes in a particular direction. Record the
results of findings.

(c.) Assuming there is harm to someone or some group, how serious is it? How likely are these harms to
occur? Record the results of the findings.

(d.) In answering these questions, assess who needs to be consulted to be sure their voices are listened to
and their perspectives, interests and practical and ethical concerns taken into account, e.g., local staff,
partners? What resources and processes are necessary to engage in these consultations? Record the
results of this analysis and describe how these will be used when engaging in the consultations required.

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 IMPLEMENTING THE RECOMMENDATIONS

(3.) Review the ethical issue in light of the information gathered

(a.) Does the process so far reveal new aspects of the ethical issue or suggest the need to reformulate or
redefine the issue? If so, what are these new aspects and how do they cause you to reformulate or
redefine the issue? Record the results of this analysis.

(b.) Refine understanding of what are the specific tensions between/among the obligations at stake. Record
the results of the assessment.

(c.) Are any obstacles related to an agency’s policies and agendas or external factors that would impede
implementation of one of the choices or options? If so, describe these obstacles and which policies,
agendas and external factors these are related to.

(d.) As a check to analysis so far, have any biases/interests affected how the organization perceives the
issue? If so, list and describe these biases and how they are affecting perceptions.

(4.) Generate, define and evaluate options

Review findings so far to determine what options are possible in this situation and what ethical and
humanitarian principles and organizational values support each decisional option and which will be
compromised or breached by each option. Record the results of the deliberative process.

(a.) What real-world consequences are likely to flow from each option? Record the results.

(b.) How do these options relate to obligations and duties of different people involved? Record the results.

(c.) Can consequences, values and obligations be reconciled? If not, what might be lost if particular options
are selected? Record the results.

(5.) Select an option, then make, document, share and store the decision

(a.) What is the selected option and the decision(s) made? Describe any factors considered that were not
recorded previously on how this decision was reached and who was involved or consulted.

(b.) What steps are required to implement the selected option? Record the steps.

(c.) Who needs to be informed and included? Record these.

(d.) What is the plan for disseminating this decision and tracking impacts? Record the elements of the plan.

(e.) What is the plan for recording and storing the decision, both for internal reference and external sharing?
Record the elements of the plan.
IMPLEMENTING THE RECOMMENDATIONS

It may be that in certain contexts, the need to described in such a way that sensitive or confidential
respond is so time-critical that the documentation information is shared that could cause personal or
process cannot be done until some time has elapsed. group harm. Generally, we recommend that the
It is also possible that these various steps may not processing and evaluation of ethical decisions and
happen in the same order or without delays or their impacts should include answering questions in
interruptions. There is still good reason to undertake writing (see Panel 6).
the steps of documentation, lest the decisions
that are made go unreported, which reduces the  ake recommendations for future
3. m
possibility that lessons might be learned and shared. action

2. implement, process, and evaluate Once an organization has processed and evaluated
decisions and their impacts a decision, ideally across various internal levels,
and in consultation with key stakeholders, it
Once a decision has been documented and should make recommendations for future action.
shared among organizational staff (and possibly This could include internal recommendations
key stakeholders—local partners, community about staff training, deployment of resources, or
leaders, etc.), organizations need to process this organizational programs and policies. Externally,
decision and its impacts. Within an organization, these recommendations might focus on
this can be done in the form of after-action reviews, processes for engagement with the community
staff briefings and meetings, and conference and local stakeholders, or recommendations
calls, as well as the documentation of these for governments or international organizations.
activities. If the processing and evaluation of this Wherever possible, these recommendations should
decision involves individuals or groups outside the not be limited to written documentation but should
organization, care must be taken that the specific involve engagement and discussion within and
details of an event or ethical challenge, the persons outside the organization.
or groups involved, and the decision made are not

(6.) Implement, process, and evaluate decisions and their impact

(a.) What, in summary, was the decision (or decisions) made and what were the impacts?

(b.) Who contributed to the assessment of impacts and what criteria were used to assess positive or negative
impact?

(c.) Was there general consensus within and outside the organization about the ethical and humanitarian
principles at stake and the impacts of the decision or did perspectives vary? If perspectives varied,
describe these in terms of how and by whom.

(d.) Looking at the decision in hindsight, how would you evaluate it now? Is there anything you would do
differently if faced with similar challenges in the future? Is there anything you would do the same?

(e.) What lessons should be learned from this decision in terms of organizational programs and policies?
What lessons should other stakeholders learn from this?

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 IMPLEMENTING THE RECOMMENDATIONS

 hare results within the

4. s psychosocial needs of staff and others supported
organization and beyond by the organization. We recognize that this
recommendation is not about organizational
Carrying on the process from the steps above, processes for ethical decision-making so much
once decisions are documented, processed and as it is about an ethical decision and commitment
evaluated, and recommendations are formulated, that organizations should make, especially
results need to be shared and discussed within and those providing humanitarian health services in
outside the organization as appropriate, e.g., with situations of extreme violence. Support should
partner organizations affected by the decisions. include programs for the psychological well-being
While the sharing of results should not be limited to of health workers and managers working in violent
written documentation, as a start we recommend contexts to help them cope with the extreme
that results take the form of a short (usually less than danger, stress, and moral distress they may
five pages) summary report as described in Panel 7. experience. Particular attention should be given,
where applicable, to the gender-specific needs of
We recommend not only sharing these results female staff.
and discussing them internally and externally but
collecting and reviewing these reports over time We recommend that organizations involve their
so that trends and patterns might be observed human resources department in identifying what
and cumulative learning takes place. Given the resources are available, within the organization
likely sensitivity of some these events and those and/or via referral, for mental health services
involved, we strongly recommend that organizations and/or psychosocial support for staff operating
take appropriate steps to protect the privacy and in situations of extreme violence. To commit to a
confidentiality of individuals and organizations. process of organizational ethical decision-making
means also making a commitment to support
those who will almost certainly experience moral
E | provide support for mental distress in the context of these decisions and their
health and psychosocial needs impacts. The Core Humanitarian Standard on
of staff Quality and Accountability (CHS Alliance, 2014)
establishes Nine Commitments that organizations
Finally, we recommend that organizations and individuals involved in humanitarian response
provide support for the mental health and can use to improve the quality and effectiveness of

(7.) Share results within the organization and beyond

(a.) Description of context, the nature of the ethical challenge or issue and who was involved or affected

(b.) Description of context, the nature of the ethical challenge or issue and who was involved or affected

(c.) Description of the decision(s) made

(d.) Discussion of impact(s), who was affected, and evaluation of harms or benefits

(e.) Recommendations on action steps and who should take them

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XXXX
IMPLEMENTING THE RECOMMENDATIONS

the assistance they provide. Commitment Number these resources, Essential principles of staff
Eight affirms that “Communities and people affected care (KonTerra Group, 2017) lays out principles
by crisis receive the assistance they require from and practices to strengthen resilience, including
competent and well-managed staff and volunteers.” Principle 6 that “Staff care policies and procedures
The “quality criterion” for this commitment is that should indicate that certain sub-sets of the staff
“Staff are supported to do their job effectively, population face greater exposure to stress and
and are treated fairly and equitably.” Among the trauma than the staff population at large. These
organizational responsibilities to meet this criterion sub-groups should be identified by name and special
are that “Policies are in place to support staff to attention should be paid and resources allocated to
improve their skills and competencies” and support these individuals.” It is not for this handbook
“Policies are in place for the security and the to delineate for any organization specifically who
wellbeing of staff.” might be included in the list of sub-groups and
individuals who face greater than usual stress and
The CHS Alliance includes links to a number of trauma but our research on Syria suggests that any
resources to support the Core Humanitarian humanitarian health worker deployed in situations
Standards, including duty of care to staff. Among of extreme violence would meet these criteria.

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 IV. A
 NNEXES

 cenarios
A | s

The following scenarios were developed from the

Syrian context. These could be used in training as
presented below, or they might be adapted to local
contexts, or they might prompt development of
entirely new scenarios.

Scenario One: Hospital closure

The decision to close a hospital damaged from bombing or because it has been a frequent target in the past is a
wrenching one. Organization members feel empowered to make the decision, but the need to do so also raised
difficult choices as well as complex feelings of having abandoned patients in need as well as staff.
In the Syrian context, some have reported that “reality makes the decision” in the sense that either because
of damage or impending attack, there was no other choice than to close. But that is not always the case. For
example, in some cases staying open allows an organization to continue to serve the population, but this puts
staff and patients in the facility at risk.
If the hospital needs to suspend or end operations, other difficult choices are sometimes posed. In relocating,
a question may arise whether to move to a safer area, with the likely result of leaving less access to a facility to
the people served by it. Some front-line workers said that they faced another difficult choice: some people in a
community said they did not want a hospital to be opened in their vicinity because its presence could put them at
greater risk. Whatever the outcome, staff members reported significant stress in making the decision.

For discussion:
(a.) What is the nature of the challenge? Are there ethical issues involved? If so, what are they?
(b.) Who is going to be hurt/helped by a decision? What is the nature of the harm to those hurt and how serious
are they? What is the nature of the benefits that might be provided and how great are they?
(c.) What ethical or humanitarian principles, and any organization values, are at stake, and what tensions may
exist among them?
(d.) What additional facts would be helpful in making a decision?
(e.) What consultations and input are important, if any?
(f.) What decision would you make (and include reference to any additional facts or assumptions)?

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ANNEXES

Scenario Two: Impartiality

Organizations working in Syria express a range of concerns about impartiality, including the challenges of working
with armed groups (of any affiliation). In terms of challenges within organizations, some staff members talk about
demands from armed groups to serve their wounded first, or hire staff from their group, or pay them in order to
transport medications or supplies. As for challenges between and among organizations, some NGOs reported
that if they operate in opposition areas but support facilities in government-controlled areas, they cannot talk
about this because of the risk to their staff. Others say that support from other organizations may be refused if
they are seen as cooperating with certain armed groups.

According to staff members:

“ Monce
any times, the fighters come with an injured soldier with them, and we have to deal with that. I remember
there were a lot of injuries because of shelling, and we were busy a lot…and a group of fighters came
with a hand shot injury which is a medium injury including no danger. When we asked the wounded man to be
patient till we finish another, they got angry and threatened us with a weapon. I was very afraid and I did not
know how to work, I felt they would shoot bullets in the hospital!

“ Aknew
nother moral challenge we faced as a medical team is when we ask for support from some organizations. We
later that these organizations refuse us because we are receiving large quantities of fighters.

For discussion:
(a.) What is the nature of the challenge? Are there ethical issues involved? If so, what are they?
(b.) Who is going to be hurt/helped by a decision? What is the nature of the harm to those hurt and how serious
are they? What is the nature of the benefits that might be provided and how great are they?
(c.) What ethical or humanitarian principles, and any organization values, are at stake, and what tensions may
exist among them?
(d.) What additional facts would be helpful in making a decision?
(e.) What consultations and input are important, if any?
(f.) What decision would you make (and include reference to any additional facts or assumptions)?

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 ANNEXES

Scenario Three: Quality of service

Organizations report a range of concerns about the quality of services, including over-crowded and under-staffed
health facilities; staff shortages and lack of qualified health workers; task-shifting (including health workers taking
on roles they are not trained or qualified for); challenges with recruitment, hiring, training, and retention of staff;
lack of access to medical resources or supplies; inability to effectively treat or save patients; and inability of
patients to access more routine forms of health care. In addition, there were reports of inequitable distributions
of quality services, staffing, and resources (border hospitals reportedly were better equipped, able to attract more
workers and more qualified staff, and had more reliable supplies than facilities farther from the borders).

According to health workers:

“ Aunderstand
s for the medical services, they are also affected. Everyone has been working on things that he does not
except that they trying to save people. For example, I am not a surgeon and not a certified
midwife, but because of the war, there have been no doctors and nurses, so we have had to deal with these
things.

“ Tsurgeries.
he biggest challenge for me was that I was a urologist, but I had to do thoracic surgeries and internal
That was so exhausting, as sometimes patients died during surgeries and I know that if they were in
a hospital in a normal situation, they could survive.

For discussion:
(a.) What is the nature of the challenge? Are there ethical issues involved? If so, what are they?
(b.) Who is going to be hurt/helped by a decision? What is the nature of the harm to those hurt and how serious
are they? What is the nature of the benefits that might be provided and how great are they?
(c.) What ethical or humanitarian principles, and any organization values, are at stake, and what tensions may
exist among them?
(d.) What additional facts would be helpful in making a decision?
(e.) What consultations and input are important, if any?
(f.) What decision would you make (and include reference to any additional facts or assumptions)?

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ANNEXES

Scenario Four: Psychosocial needs and support

Health workers described a range of traumatic experiences, as well as psychological symptoms and burdens
resulting from these experiences. These included: feelings of fear, stress, nervousness/anxiety, pressure, guilt,
anger, isolation, hopelessness, depression, boredom, difficulty concentrating or sleeping, and confusion. These
feelings result from living under violent conditions, fearing attack and loss of life, working in volatile settings,
having an intense work-load, not having enough time for rest or to spend with family, and having to work outside
one's area of training/ skill. Health workers also experienced distress, frustration, and guilt when not able to
help or save patients or not able to perform their jobs in the way they were trained. They said this happens when
there are not enough staff, supplies, or equipment, and describe having to prioritize care for some patients over
others in desperate need, due to limited resources. Many described numbing and repressing feelings, "not letting
conditions affect us," and that they were forced to adapt to circumstances or, as organization or clinic leaders, to
hide their emotions.
Health workers and organization managers had different views about the value of psychosocial support for
themselves. Some thought these were not necessary or helpful, while others felt that their organizations should
provide psychosocial support. Some female participants experienced harassment during home visits and desired
accompaniment from male staff but did not know how to get this support from their organizations. Others wished
for more opportunities for breaks.

For discussion:
(a.) What is the nature of the challenge? Are there ethical issues involved? If so, what are they?
(b.) Who is going to be hurt/helped by a decision? What is the nature of the harm to those hurt and how serious
are they? What is the nature of the benefits that might be provided and how great are they?
(c.) What ethical or humanitarian principles, and any organization values, are at stake, and what tensions may
exist among them?
(d.) What additional facts would be helpful in making a decision?
(e.) What consultations and input are important, if any?
(f.) What decision would you make (and include reference to any additional facts or assumptions)?

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 ANNEXES

B | ethical decision-making worksheets

(1.) Identify and clarify the initial question and ethical issue 1.

make and document decisions that involve ethical challenges

(e.) What decision must be made? What are the ethical and humanitarian obligations and organizational values at
stake in making it? What frameworks—organizational or more general—are you using to answer this question?
Are there conflicts between/among the values and obligations surrounding the question? Record the results of the
initial assessment.

(f.) Does this decision involve a choice between multiple “goods” or between multiple “bads” or between different
“goods” and “bads”? Might each choice result in a benefit, but the benefit of each can’t be realized by the other
choice; might any decision made result in harm? Record the results of the assessment.

(g.) Could the result of a potential decision be damaging to someone or to some group? If so, who are those individuals
or groups? (be careful if sharing these documents beyond a limited number of people directly involved in the
issue, so as not to disclose personally identifiable information or other sensitive details). Record the results of the
assessment.

(h.) Is the right decision apparent, but cannot be implemented due to features of the situation? If yes, describe these
constraining features.
 ANNEXES
XXXX

1. (2.) Gather additional information

make and document decisions that involve ethical challenges

(e.) What are the likely consequences of various decisions/options as to who is affected and what the effects are?
Record what the consequences are and to whom.

(f.) Look more deeply at information on who is harmed if a decision goes in a particular direction. Record the results of
findings.

(g.) Assuming there is harm to someone or some group, how serious is it? How likely are these harms to occur? Record
the results of the findings.

(h.) In answering these questions, assess who needs to be consulted to be sure their voices are listened to and their
perspectives, interests and practical and ethical concerns taken into account, e.g., local staff, partners? What
resources and processes are necessary to engage in these consultations? Record the results of this analysis and
describe how these will be used when engaging in the consultations required.
 ANNEXES

(3.) Review the ethical issue in light of the information gathered 1.

make and document decisions that involve ethical challenges

(e.) Does the process so far reveal new aspects of the ethical issue or suggest the need to reformulate or redefine the
issue? If so, what are these new aspects and how do they cause you to reformulate or redefine the issue? Record the
results of this analysis.

(f.) Refine understanding of what are the specific tensions between/among the obligations at stake. Record the results
of the assessment.

(g.) Are any obstacles related to agency’s policies and agendas or external factors that would impede implementation of
one of the choices or options? If so, describe these obstacles and which policies, agendas and external factors these
are related to.

(h.) As a check to analysis so far, have any biases/interests affected how the organization perceives the issue? If so, list
and describe these biases and how they are affecting perceptions.

Ethical Decision-Making in Humanitarian Health in Situations of Extreme Violence: Organizational Handbook

 ANNEXES
XXXX

1. (4.) Generate, define, and evaluate options

make and document decisions that involve ethical challenges

Review findings so far to determine what options are possible in this situation and what ethical and humanitarian
principles and organizational values support each decisional option and which will be compromised or breached by
each option. Record the results of the deliberative process.

(d.) What real-world consequences are likely to flow from each option? Record the results.

(e.) How do these options relate to obligations and duties of different people involved? Record the results.

(f.) Can consequences, values and obligations be reconciled? If not, what might be lost if particular options are selected?
Record the results.
 ANNEXES

(5.) Select an option, then make, document, share, and store the decision 1.

make and document decisions that involve ethical challenges

(f.) What is the selected option and the decision(s) made? Describe any factors considered that were not recorded
previously on how this decision was reached and who was involved or consulted.

(g.) What steps are required to implement the selected option? Record the steps.

(h.) Who needs to be informed and included? Record these.

(i.) What is the plan for disseminating this decision and tracking impacts? Record the elements of the plan.

(j.) What is the plan for recording and storing the decision, both for internal reference and external sharing? Record the
elements of the plan.
 ANNEXES

2. (1.) What, in summary, was the decision (or decisions) made and what were the impacts?
implement, process, and evaluate decisions and their impacts

(2.) Who contributed to assessment of impacts and what criteria were used to assess positive or negative impact?

(3.) Was there general consensus within and outside the organization about the ethical and humanitarian principles at
stake and the impacts of the decision or did perspectives vary? If perspectives varied, describe these in terms of how
and by whom.

(4.) Looking at the decision in hindsight, how would you evaluate it now? Is there anything you would do differently if
faced with similar challenges in the future? Is there anything you would do the same?

(5.) What lessons should be learned from this decision in terms of organizational programs and policies? What lessons
should other stakeholders learn from this?
 ANNEXES

While the sharing of results should not be limited to written documentation, as a start we recommend that results take the
form of a short (usually less than five pages) summary report describing the following:

(1.) Description of context, the nature of the ethical challenge or issue and who was involved or affected. 4.

share results within the organization and beyond

(2.) Description of context, the nature of the ethical challenge or issue and who was involved or affected.

(3.) Description of the decision(s) made.

(4.) Discussion of impact(s), who was affected, and evaluation of harms or benefits.

(5.) Recommendations on action steps and who should take them.

ANNEXES
XXXX

C | references and resources

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Fraser V, Hunt MR, De Laat S, Schwartz L. The development of a Humanitarian Health Ethics Analysis Tool.
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https://humanitarianhealthethics.net.
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|  34  | Ethical Decision-Making in Humanitarian Health in Situations of Extreme Violence: Organizational Handbook

 V. ACKNOWLEDGEMENTS

Leonard Rubenstein was overall project director We express our deep appreciation for the health
and principal investigator, and W. Courtland workers and organizational managers who were
Robinson was co-principal investigator. Other willing to share their experience and reflections
investigators included (in alphabetical order) on the ethical challenges they have faced in
Mohammad Darwish, Matthew DeCamp, extraordinarily difficult circumstances, and to
Lara Ho, Wasim Maziak, Ahmad Mhidi, Diana Rayes, the many people and organizations who
Abdulghani Sankari, and Namrita S. Singh. participated in workshops in Gaziantep, Turkey
Mohamad Katoub was project director for SAMS in and Amman, Jordan.
Gaziantep, Turkey, with administrative coordination
by Mai Damour. Khaldoun al-Amire was project This research was funded by Elrha’s Research for
director for IRC in Amman, Jordan. Shannon Seopaul Health in Humanitarian Crises (R2HC) program,
provided administrative coordination at Johns funded equally by the Wellcome Trust and DFID,
Hopkins. Grant Broussard, Nermin Diab, Kory Funk, with Elrha overseeing the program’s execution
and Sappho Gilbert were student investigators. and management.
Brittany Redman was a research assistant on
the project.

We thank Caroline Clarinval for her very helpful

comments on an earlier draft of this handbook,
and we thank graphic designer Andrew Bell for his
creative vision, design efforts, and attention to detail
on this handbook.

Ethical Decision-Making in Humanitarian Health in Situations of Extreme Violence: Organizational Handbook |  35  |

© cosimoattanasio/Redline/Shutterstock.com ↓

contact Center for Public Health and Human Rights

Telephone: +1 443-287-4739
JHSPH.CPHHR@gmail.com

this report was supported by

|  36  | Ethical Decision-Making in Humanitarian Health in Situations of Extreme Violence: Organizational Handbook