The Protection of Civilians and ethics of humanitarian governance: beyond intervention and resilience

The principle of the Protection of Civilians (PoC) in armed conflict has ethical repercussions in various actions undertaken by states and international organisations, from humanitarian relief, development aid, and peacekeeping, to warfare and military intervention. While the ethics of humanitarian intervention are instructive in this regard, most PoC practices should be conceived rather as modes of humanitarian governance across borders-from interventionist to resilience-oriented kinds. The consequences of this for the ethics of PoC are explored in this paper, highlighting questions of power, culture, and complicity. By relating these questions to the ethical strands of solidarist and pluralist internationalism, it positions the ethics of PoC within the broader field of the ethics of world politics. Examples are drawn from recent scholarly debate on PoC efforts in war-torn countries such as South Sudan. This analysis of the ethics of PoC reconfigures central positions in the debate on humanitarian intervention to an era of global humanitarian governance.

Humanitarian medical aid to the Syrian people: Ethical implications and dilemmas

Medical professionals providing humanitarian aid in times of crisis face complicated ethical and clinical challenges. Today, humanitarian aid is given in accordance with existing guidelines developed by international humanitarian organizations and defined by international law. This paper considers the ethical aspects and frameworks of an atypical humanitarian project, namely one that provides medical support through an Israeli civilian hospital to Syrian Civil War casualties. We explore new ethical questions in this unique situation that pose a serious challenge for the medical community and conventional ethical norms, a challenge Israeli medical staff meet on a daily basis. Before discussing the ethical challenges, we give a description of the project and its unique status.

Newborns in crisis: An outline of neonatal ethical dilemmas in humanitarian medicine

Newborn infants are among those most severely affected by humanitarian crises. Aid organisations increasingly recognise the necessity to provide for the medical needs of newborns, however, this may generate distinctive ethical questions for those providing humanitarian medical care. Medical ethical approaches to neonatal care familiar in other settings may not be appropriate given the diversity and volatility of humanitarian disasters, and the extreme resource limitations commonly faced by humanitarian aid missions.

In this paper, we first systematically review existing guidelines relating to the treatment and resuscitation of newborns in humanitarian crises, finding little substantive ethical guidance for those providing humanitarian healthcare. We next draw on paradigm cases and published literature to identify and describe some of the major ethical questions common to these settings. We divide these questions into quality of life considerations, allocation of limited resources, and conflicting cultural norms and values. We finally suggest some preliminary recommendations to guide ethical decision‐making around resuscitation of newborns and withdrawal of treatment in humanitarian settings.

'He who helps the guilty, shares the crime'? INGOs, moral narcissism and complicity in wrongdoing

Humanitarian organisations often work alongside those responsible for serious wrongdoing. In these circumstances, accusations of moral complicity are sometimes levelled at decision makers. These accusations can carry a strong if unfocused moral charge and are frequently the source of significant moral unease. In this paper, we explore the meaning and usefulness of complicity and its relation to moral accountability. We also examine the impact of concerns about complicity on the motivation of humanitarian staff and the risk that complicity may lead to a retreat into moral narcissism. Moral narcissism is the possibility that where humanitarian actors inadvertently become implicated in wrongdoing, they may focus more on their image as self-consciously good actors than on the interests of potential beneficiaries. Moral narcissism can be triggered where accusations of complicity are made and can slew decision making. We look at three interventions by Médecins Sans Frontières that gave rise to questions of complicity. We question its decision-guiding usefulness. Drawing on recent thought, we suggest that complicity can helpfully draw attention to the presence of moral conflict and to the way International Non-Governmental Organisations (INGOs) can be drawn into unintentional wrongdoing. We acknowledge the moral challenge that complicity presents to humanitarian staff but argue that complicity does not help INGOs make tough decisions in morally compromising situations as to whether they should continue with an intervention or pull out.

The Elephant in the room: toward a more ethical approach with accountability toward intended beneficiaries in humanitarian aid

There is considerable tension between the concept of accountability to beneficiaries and its practice in humanitarian aid. The beneficiaries live in a relationship that is asymmetric; upward or horizontal accountability within the aid system alone-even with the best of intentions-might be short-sighted. Could beneficiaries be effectively involved in programing, priority setting or allocation of resources? Is there space for a rights-based approach in aid delivery and operations? The mind-set, governance and structure of operations in aid agencies may need significant institutional reform to share the process of decision-making, and to transform the current dynamic from connecting resources to brokering better governance, true collaboration and co-operation among all stakeholders. This article provides a background and overview of accountability in aid, sheds light onto its underlying challenges, and positive and negative effects through the lens of organizational and social ethics, explores practical and feasible ways to strengthen beneficiaries' participation and empowerment, and call upon aid agencies to integrate beneficiaries' views in aid operations, and exercise true solidarity.

Ethical questions identified in a study of local and expatriate responders' perspectives of vulnerability in the 2010 Haiti earthquake

BACKGROUND

Situations of disaster that prompt international humanitarian responses are rife with ethical tensions. The 2010 Haiti earthquake caused great destruction and prompted a massive humanitarian response. The widespread needs experienced by the population and the scale of the response inevitably rendered priority-setting difficult, and gave rise to ethical challenges.

PURPOSE

This paper presents four ethical questions identified in the analysis of a study on vulnerability and equity in the humanitarian response to the 2010 Haiti earthquake.

METHODS

Using interpretive description methodology, the interdisciplinary research team analysed 24 semi-structured in-depth interviews conducted with expatriate and Haitian health workers and decision-makers involved in the response.

RESULTS

Ethical questions identified through the analysis were: (1) How should limited resources be allocated in situations of widespread vulnerability and elevated needs? (2) At what point does it become ethically problematic to expend (considerable) resources to sustain expatriate disaster responders? (3) How ought rapid and reactive interventions be balanced with more deliberated and coordinated approaches? (4) What trade-offs are justified when interventions to address acute needs could contribute to long-term vulnerabilities?

DISCUSSION

The questions arise in light of an immense gap between available resources and widespread and elevated needs. This gap is likely unavoidable in large-scale crises and may be a source of ethical distress for both local and international responders. The analysis of ethical questions associated with crisis response can advance discussions about how relief efforts can best be designed and implemented to minimise ethical distress and improve assistance to local populations.

Ethical problems in an era where disasters have become a part of daily life: A qualitative study of healthcare workers in Turkey

Background

Natural disasters, armed conflict, migration, and epidemics today occur more frequently, causing more death, displacement of people and economic loss. Their burden on health systems and healthcare workers (HCWs) is getting heavier accordingly. The ethical problems that arise in disaster settings may be different than the ones in daily practice, and can cause preventable harm or the violation of basic human rights. Understanding the types and the determinants of ethical challenges is crucial in order to find the most benevolent action while respecting the dignity of those affected people. Considering the limited scope of studies on ethical challenges within disaster settings, we set upon conducting a qualitative study among local HCWs.

Methods

Our study was conducted in six cities of Turkey, a country where disasters are frequent, including armed conflict, terrorist attacks and a massive influx of refugees. In-depth interviews were carried out with a total of 31 HCWs working with various backgrounds and experience. Data analysis was done concurrently with ongoing interviews.

Results

Several fundamental elements currently hinder ethics in relief work. Attitudes of public authorities, politicians and relief organizations, the mismanagement of impromptu humanitarian action and relief and the media's mindset create ethical problems on the macro-level such as discrimination, unjust resource allocation and violation of personal rights, and can also directly cause or facilitate the emergence of problems on the micro-level. An important component which prevents humanitarian action towards victims is insufficient competence. The duty to care during epidemics and armed conflicts becomes controversial. Many participants defend a paternalistic approach related to autonomy. Confidentiality and privacy are either neglected or cannot be secured.

Conclusion

Intervention in factors on the macro-level could have a significant effect in problem prevention. Improving guidelines and professional codes as well as educating HCWs are also areas for improvement. Also, ethical questions exposed within this study should be deliberated and actualized with universal consensus in order to guide HCWs and increase humane attitudes.

[The Humanitarian Charter and minimum standards in humanitarian response are applicable in German refugee facilities]

BACKGROUND

In recent refugee migration into Germany the responsibilities and reactions of health authorities are still lacking general co-ordination.

PROBLEM

Can the ethical and technical standards of international humanitarian assistance serve as an appropriate and even a compulsory guideline for relief agencies, public health and regulatory authorities in Germany?

METHODS

Documents from the field of medical ethics, medical law, international humanitarian law and disaster medicine will be examined and checked for practicability by consulting experiences during the 1990s Balkan wars refugee movement and international missions of relief agencies.

RESULTS

Ethical and technical standards of international humanitarian assistance have been developed, improved and evaluated for 20 years, and are valuable tools for emergency management.

CONCLUSIONS

Victims of disaster or conflict have a right to live in dignity and therefore have a right to receive health care according to international standards. International ethical and technical standards for refugees should be considered in the Federal Republic of Germany like in any other country.

Virtues and humanitarian ethics

This paper analyses the contribution of virtue ethics, the study of good character traits, to the humanitarian context. It argues that a virtue ethics perspective paints a realistic picture of the use of ethical standards in morally complex circumstances. Virtuous relief workers can employ standards in their thinking, but they are also committed to professional excellence that goes beyond any formal code. The concept of virtue ethics places a stress on moral development, which can be facilitated by role models that impart modest and feasible ideals. However, virtue ethics cannot provide simple guidelines on how to resolve difficult situations. It is possible that two virtuous persons can disagree on what should be done in a particular instance. In addition, a virtue ethics perspective emphasises the need for both individuals and organisations to discuss the actual purpose of relief work in order to pinpoint the virtues of a good relief professional.

Ethical and clinical dilemmas in patients with head and neck tumors visiting a field hospital in the Philippines

OBJECTIVE

To describe clinical and ethical dilemmas in patients presenting with head and neck (H&N) tumors to a field hospital in the "subacute" period following a typhoon.

METHODS

We retrospectively reviewed charts of H&N patients presenting to an integrated Israeli-Filipino medical facility, which was operated more than 11 days.

RESULTS

Of the 1,844 adult patients examined, 85 (5 percent) presented with H&N tumors. Of those, 70 (82 percent) were females, with a mean age of 43 ± 15 years. Thyroid neoplasms were the most common tumors (68, 80 percent). Despite limited resources, we contributed to the workup and treatment of several patients. To better illustrate our dilemmas, we present four key patients, in whom we favored diagnostic/therapeutic interventions in two, and opted to defer any intervention in two.

CONCLUSIONS

In a relief mission, despite the lack of clinical and pathological staging and questionable continuity of care, surgical interventions can be considered for therapeutic, palliative, and diagnostic purposes.

Ending neglect of older people in the response to humanitarian emergencies

Unni Karunakara and Frances Stevenson argue that humanitarian policy and practice must adapt to ensure that the needs of older people in humanitarian emergencies are addressed.

Preventing corruption in humanitarian assistance: perceptions, gaps and challenges

Corruption is a threat to the purpose of humanitarian assistance. Until fairly recently, humanitarian assistance has not been considered an important arena in broader efforts aimed at curbing corruption, and corruption has not always been considered a particularly important concern for humanitarian assistance despite the obviously challenging nature of the context of humanitarian emergencies. Corruption, though, is a threat to humanitarian action because it can prevent assistance from getting to the people who most need it, and because it can potentially undermine public support for such assistance. This paper examines perceptions of corruption and its affects, documents best practices, and outlines gaps in understanding. It suggests recommendations for improving the capacity of humanitarian agencies to prevent and manage the risk of corruption. Agencies have taken steps to combat corruption and improve accountability--downwards and upwards--but scope remains for improvement and for greater sharing of learning and good practice.

Denial of flood aid to members of the Ahmadiyya Muslim community in Pakistan

During the catastrophic floods of 2010 in Pakistan, approximately 500 internally displaced families belonging to the Ahmadiyya sect of Islam were denied humanitarian relief. The failure of international agencies and Pakistan's government to protect basic human rights in the context of disaster relief raises profound questions. If all humanitarian work associated with natural disasters must be governed by canons of human rights, how should international agencies deal with legally empowered official discrimination? A review of the history of the Ahmadiyya community in Pakistan reveals decades of state-sanctioned persecution, particularly through its anti-blasphemy laws, and poses a serious challenge to the international community. When effective intervention is predicated on cooperation with state institutions, how can international relief agencies avoid becoming implicated in official discrimination? The denial of flood aid to Pakistan's Ahmadiyya community highlights the need for concerted action in disaster settings to prevent discrimination against vulnerable groups. Discriminatory legislation is not only a violation of basic norms enshrined in international compacts, it is a key problem for disaster relief.

Lessons from the Chilean earthquake: how a human rights framework facilitates disaster response

The earthquake of 2010 in Chile holds important lessons about how a rights-based public health system can guide disaster response to protect vulnerable populations. This article tells the story of Chile Grows With You (Chile Crece Contigo), an intersectoral system created three years before the earthquake for protection of child rights and development, and its role in the disaster response. The creation of Chile Grows With You with an explicit rights-oriented mandate established intersectoral mechanisms, relationships, and common understanding between governmental groups at the national and local levels. After the earthquake, Chile Grows With You organized its activities according to its founding principles: it provided universal access and support for all Chilean children, with special attention and services for those at greatest risk. This tiered approach involved public health and education materials for all children and families; epidemiologic data for local planners about children in their municipalities at-risk before the earthquake; and an instrument developed to assist in the assessment and intervention of children put at risk by the earthquake. This disaster response illustrates how a rights-based framework defined and operationalized in times of stability facilitated organization, prioritization, and sustained action to protect and support children and families in the acute aftermath of the earthquake, despite a change in government from a left-wing to a right-wing president, and into the early recovery period.

Establishing moral bearings: ethics and expatriate health care professionals in humanitarian work

Expatriate health care professionals frequently participate in international responses to natural disasters and humanitarian emergencies. This field of practice presents important clinical, logistical and ethical challenges for clinicians. This paper considers the ethics of health care practice in humanitarian contexts. It examines features that contribute to forming the moral landscape of humanitarian work, and discusses normative guidelines and approaches that are relevant for this work. These tools and frameworks provide important ethics resources for humanitarian settings. Finally, it elaborates a set of questions that can aid health care professionals as they analyse ethical issues that they experience in the field. The proposed process can assist clinicians as they seek to establish their moral bearings in situations of ethical complexity and uncertainty. Identifying and developing ethics resources and vocabulary for clinical practice in humanitarian work will help health care professionals provide ethically sound care to patients and communities.

[Humanitarian ethics and the concept of justice]

The bases of humanitarian assistance, beyond a legal norm--which appears to be essential given the inalienable obligations that result for all participating bodies--are influenced by philosophical and political conceptualizations framed in an ethics of justice. Actors in the humanitarian field who adhere to the Rawlsian social contract model their actions based on a philosophy that assistance is a noble and desirable option that remains in the hands of those who offer aid, and who can freely choose to not offer such assistance. Peter Singer and Thomas Pogge propose nuances to the understanding of the duty of assistance. Not assisting would be bad, basically tantamount to killing. Assistance is no longer a caring act deserving of praise, but rather a moral obligation. The financial imperatives of associations, the growing complexity of activities and the development of an important element of communication lead to a professionalization of humanitarian medicine. A modern vision of humanitarian assistance requires an understanding of justice and solidarity and global outreach. We believe that ethics need to be embedded firmly in humanitarian actions that have clear political implications.

The Union and Médecins Sans Frontières approach to operational research

Operational research (OR) has become a hot topic at national meetings, international conferences and donor fora. The International Union Against Tuberculosis and Lung Disease (The Union) and Médecins Sans Frontières (MSF) Operational Centre Brussels strongly promote and implement OR with colleagues in low- and middle-income countries. Here we describe how the two organisations define OR, and explain the guiding principles and methodology that underpin the strategy for developing and expanding OR in those countries. We articulate The Union's and MSF's approach to supporting OR, highlighting the main synergies and differences. Then, using the Malawi National Tuberculosis Control Programme as an example, we show how OR can be embedded within tuberculosis control activities, leading to changes in policy and practice at the national level. We discuss the difficult, yet vitally important, issue of capacity building, and share our vision of a new paradigm of product-related training and performance-based OR fellowships as two ways of developing the necessary skills at country level to ensure research is actually performed. Finally, we highlight the need to consider and incorporate into practice the ethical components of OR. This is a key moment to be involved in OR. We are confident that in partnership with interested stakeholders, including the World Health Organization, we can stimulate the implementation of quality, relevant OR as an integral part of health service delivery that in turn will lead to better health for people, particularly for those living in the poorer parts of the world.

Ritual dynamics in humanitarian assistance

Those who intervene in crises must take care to ensure that assistance does not undermine the processes through which social cohesion is generated or restored. From a neo-Durkheimian analytical perspective, feeding creates social loyalties as well as saves lives. Humanitarian agencies provide practical assistance to livelihoods, but they need also to create space for the ritual agency on which social cohesion depends. Attention to the rituals of food distribution helps humanitarian actors to address a potentially damaging dissociation between social and material facts. A post-war food security project in Sierra Leone is used to illustrate the point. The lessons of this intervention have implications for the organisation of humanitarian assistance at all levels, both international and local. The paper argues that establishing space for ritualisation within humanitarian programmes is an obligation for those who wish to do no harm.

The humanitarians' tragedy: escapable and inescapable cruelties

Paradoxically, elements of cruelty are intrinsic to the humanitarian enterprise.(1) This paper focuses on some of these. Escapable cruelties arise from technical failings, but the gradual professionalisation of the field and improvements in relief technologies mean that they have been significantly reduced in comparison to earlier eras. Other cruelties arise from clashes among rights, and the tensions inherent in trying to promote humanity amid the horrors of war. These are inescapable and constitute the 'humanitarians' tragedy'. Among them is the individual cruelty of failing to do good at the margin: a clash between the individual's impulses and ideals and the constraints of operating in constrained circumstances. This is a version of triage. In addition, there is the cruelty of compromising dearly-held principles when faced with other competing or overriding demands. There is also the cruelty whereby humanitarians feed victims' dreams that there is an alternative reality, which in fact cannot be attained.

Forced displacement and women's security in Colombia

In the protracted Colombian conflict, assistance to internally displaced persons has developed in the context of contradictory political processes. The Colombian government's launching of a transitional justice process in the midst of armed conflict has generated a complex situation displaying both conflict and post-conflict characteristics. The progressive Constitutional Court rulings on internal displacement, in particular the gender-sensitive Auto 092, constitute an attempt to bring together humanitarian interventions and transitional justice measures in a rights-based framework. However, the national government is reluctant to adopt them fully and local realities still hamper their integrated implementation. Displaced women, therefore, remain in an especially vulnerable position. This paper argues that gender-sensitive humanitarian interventions must take into account all of these complexities of scale and political process in order to make legal frameworks more effective at the local level. In these contexts, interventions should pay particular attention to strategies that contribute to transforming pre-existing gender regimes.

Livelihoods and protection in situations of protracted conflict

This paper presents the findings from research on livelihoods-protection linkages from the perspective of conflict-affected populations as well as agency analysis and action. The aim of the research is to understand how greater complementarity between humanitarian protection and livelihoods approaches might reduce the risks facing conflict-affected populations. The findings show that the causes of risks to livelihoods and protection are often the same, and that community responses are intimately connected, providing good rationale for linking operational approaches. There are four main ways in which this can be done. First, by targeting those confronting the greatest risks. Second, by addressing the causes of risks through advocacy and capacity-building. Third, by implementing livelihoods interventions that minimise the need to adopt unsafe livelihood strategies and that address humanitarian consequences. Fourth, by making sure that livelihoods programming does not pose additional risks.

The elephant in the room: collaboration and competition among relief organizations during high-profile disasters

The non-governmental organizations (NGOs) that assume the bulk of emergency care during large-scale disasters in the developing world must expend considerable time and resources to ensure donations to sustain their field operations. This long-standing dilemma for the humanitarian community can create a competitive environment that: Compromises the delivery and quality of services, Allows the effectiveness of operations to be compromised by a lack of cooperation and collaboration, Disrupts the timely and accurate coordination and analysis of outcome measures that are crucial to successful response in the future, and Undermines the long-term capacity of indigenous aid organizations. This article addresses problems and potential solutions for improved coordination and long-term capacity-building of humanitarian aid.

Resources and constraints for addressing ethical issues in medical humanitarian work: experiences of expatriate healthcare professionals

OBJECTIVE

International nongovernmental organizations frequently provide emergency assistance in settings where armed conflict or natural disaster overwhelm the capacity of local and national agencies to respond to health and related needs of affected communities. Healthcare practice in humanitarian settings presents distinct clinical, logistical, and ethical challenges for clinicians and differs in important ways from clinical practice in the home countries of expatriate healthcare professionals. The aim of this research was to examine the moral experience of healthcare professionals who participate in humanitarian relief work.

DESIGN

I conducted a qualitative research study using interpretive description methodology.

PARTICIPANTS

Fifteen Canadian healthcare professionals and three human resource or field coordination officers for nongovernmental organizations were interviewed.

RESULTS

In this article, I present findings related to expatriate healthcare professionals' experiences of resources and constraints for addressing ethical issues in humanitarian crises. Resources for ethics deliberation and reflection include the following: opportunities for discussion; accessing and understanding local perspectives; access to outside perspectives; attitudes, such as humility, open-mindedness, and reflexivity; and development of good moral "reflexes." Constraints for deliberation and reflection relate to three domains: individual considerations, contextual features of humanitarian relief work, and local team and project factors.

CONCLUSION

These findings illuminate the complex nature of ethical reflection, deliberation, and decision-making in humanitarian healthcare practice. Healthcare professionals and relief organizations should seek to build upon resources for addressing ethical issues. When possible, they should minimize the impact of features that function as constraints.

Ethical issues in conduct of research in combat and disaster operations

BACKGROUND

The conduct of research in the combat and disaster environments shares many of the same fundamental principles and regulations that govern civilian biomedical research. However, Department of Defense research protocols stipulate additional requirements designed to preserve servicemembers' informed consent rights, uphold ethical standards, and protect sensitive or classified information. The authors reviewed studies that have been approved for the conduct of research in current combat operations and also discuss their applicability in disaster settings.

METHODS

This is a descriptive, retrospective study of protocols that have currently been approved for conduct of research in Operation Iraqi Freedom and Operation Enduring Freedom.

RESULTS

During the period of July 2005 through October 2007, 38 retrospective chart review protocols, seven prospective studies requiring consent or an alteration of the consent document and 12 prospective observational studies were submitted through the Deployed Research Committee in Iraq for review and approval at the Brooke Army Medical Center Institutional Review Board (IRB). A total of 55 protocols were approved by the IRB for implementation in the Iraq combat theater. Most of these protocols involved trauma care treatment. One prospective study investigating the effects of blast-concussive injuries on US Soldiers in Iraq requiring informed consent was reviewed and approved.

CONCLUSIONS

The conduct of military medical research has, and will make, significant and lasting contributions to the practice of both civilian and military medicine. Although policies and regulations to conduct research and release-associated findings often seem cumbersome and stringent, these added hurdles serve not only to ensure protection of the rights of human subjects during a time of potentially increased vulnerability, but also to protect the security interests of US troops. Many of these principles and practices are directly applicable in disaster research environments.

Public healthcare resource allocation and the Rule of Rescue

In healthcare, a tension sometimes arises between the injunction to do as much good as possible with scarce resources and the injunction to rescue identifiable individuals in immediate peril, regardless of cost (the "Rule of Rescue"). This tension can generate serious ethical and political difficulties for public policy makers faced with making explicit decisions about the public funding of controversial health technologies, such as costly new cancer drugs. In this paper we explore the appropriate role of the Rule of Rescue in public resource allocation decisions by health technology funding advisory bodies such as the National Institute for Health and Clinical Excellence. We consider practical approaches to operationalising the Rule of Rescue from Australia and the UK before examining the relevance of individual moral imperatives to public policy making. We conclude that that whilst public policy makers in a humane society should facilitate exceptional departures from a cost effectiveness norm in clinical decisions about identified individuals, it is not so obvious that they should, as a matter of national public policy, exempt any one group of unidentified individuals within society from the rules of opportunity cost at the expense of all others.

Faith-based NGOs and healthcare in poor countries: a preliminary exploration of ethical issues

An increasing number of non-governmental organisations (NGOs) provide humanitarian assistance, including healthcare. Some faith-based NGOs combine proselytising work with humanitarian aid. This can result in ethical dilemmas that are rarely discussed in the literature. The article explores several ethical issues, using four generic activities of faith-based NGOs: (1) It is discriminatory to deny aid to a needy community because it provides less opportunity for proselytising work. Allocating aid to a community with fewer health needs but potential for proselytising work is unjust, since it neither maximises welfare (utilitarianism) nor assists the most needy (egalitarianism). (2) Faith-based-NGOs may state that proselytising work combined with humanitarian assistance improves spiritual wellbeing and overall benefit. However, proselytising work creates religious doubts, which could transiently decrease wellbeing. (3) Proselytising work is unlikely to be a perceived need of the population and, if carried out without consent, breaches the principle of autonomy. Such work also exploits the vulnerability of disaster victims. (4) Governments that decline the assistance of a faith-based NGO involved in proselytising work may deprive the needy of aid. Three strategies are proposed: (a) Increase knowledge to empower communities, individuals and governments; information on NGOs could be provided through an accessible register that discloses objectives, funding sources and intended spiritual activities. (b) Clearly demarcate between humanitarian aid from proselytising work, by setting explicit guidelines for humanitarian assistance. (c) Strengthen self-regulation by modifying the Code of Conduct of the Red Cross to state criteria for selecting communities for assistance and procedures for proselytising work.

EXPLORING DISPARITIES BETWEEN GLOBAL HIV/AIDS FUNDING AND RECENT TSUNAMI RELIEF EFFORTS: AN ETHICAL ANALYSIS

OBJECTIVE

To contrast relief efforts for the 26 December 2004 tsunami with current global HIV/AIDS relief efforts and analyse possible reasons for the disparity.

METHODS

Literature review and ethical analysis.

RESULTS

Just over 273,000 people died in the tsunami, resulting in relief efforts of more than US$10 bn, which is sufficient to achieve the United Nation's long-term recovery plan for South East Asia. In contrast, 14 times more people died from HIV/AIDS in 2004, with UNAIDS predicting a US$8 bn funding gap for HIV/AIDS in developing nations between now and 2007. This disparity raises two important ethical questions. First, what is it that motivates a more empathic response to the victims of the tsunami than to those affected by HIV/AIDS? Second, is there a morally relevant difference between the two tragedies that justifies the difference in the international response? The principle of justice requires that two cases similarly situated be treated similarly. For the difference in the international response to the tsunami and HIV/AIDS to be justified, the tragedies have to be shown to be dissimilar in some relevant respect. Are the tragedies of the tsunami disaster and the HIV/AIDS pandemic sufficiently different, in relevant respects, to justify the difference in scope of the response by the international community?

CONCLUSION

We detected no morally relevant distinction between the tsunami and the HIV/AIDS pandemic that justifies the disparity. Therefore, we must conclude that the international response to HIV/AIDS violates the fundamental principles of justice and fairness.

Literature review: Afghanistan women's health crisis, health service delivery, and ethical issues for international aid

The literature indicates that the health of women in Afghanistan is poor. In 1997 maternal mortality in Afghanistan was one of the worst in the world. Difficulties in establishing health services revolve around fundamentalist Islamic ideas and ongoing violence within Afghanistan. The literature holds advice on key behaviours for health professionals who may chose to work in Afghanistan. The literature also identifies the local level action that is occurring as the issue of women's health is recognised. Humanitarian assistance has been provided, with international aid agencies having to weigh the ethical responsibilities they hold and one agency tragically facing the violent loss of its own staff. Easy answers are not in the literature, merely an opportunity to understand, consider, and take action about what is facing women in Afghanistan and those who try to help.

Do aid agencies have an ethical duty to comply with researchers? A response to Rennie

Medical AID organisations such as Médecins Sans Frontières receive several requests from individuals and international academic institutions to conduct research at their implementation sites in Africa. Do AID agencies have an ethical duty to comply with research requests? In this paper we respond to the views and constructed theories (albeit unfounded) of one such researcher, whose request to conduct research at one of our sites in the Democratic Republic of Congo was turned down.

Justified commitments? Considering resource allocation and fairness in Medecins sans Frontieres-Holland

Non-governmental aid programs are an important source of health care for many people in the developing world. Despite the central role non-governmental organizations (NGOs) play in the delivery of these vital services, for the most part they either lack formal systems of accountability to their recipients altogether, or have only very weak requirements in this regard. This is because most NGOs are both self-mandating and self-regulating. What is needed in terms of accountability is some means by which all the relevant stakeholders can have their interests represented and considered. An ideally accountable decision-making process for NGOs should identify acceptable justifications and rule out unacceptable ones. Thus, the point of this paper is to evaluate three prominent types of justification given for decisions taken at the Dutch headquarters of Médecins sans Frontières. They are: population health justifications, mandate-based justifications and advocacy-based justifications. The central question at issue is whether these justifications are sufficiently robust to answer the concerns and objections that various stakeholders may have. I am particularly concerned with the legitimacy these justifications have in the eyes of project beneficiaries. I argue that special responsibilities to certain communities can arise out of long-term engagement with them, but that this type of priority needs to be constrained such that it does not exclude other potential beneficiaries to an undesirable extent. Finally, I suggest several new institutional mechanisms that would enhance the overall equity of decisions and so would ultimately contribute to the legitimacy of the organization as a whole.

ETHICAL CONSIDERATIONS FOR CLINICAL PHOTOGRAPHY IN THE GLOBAL SOUTH

Clinical photography is an important tool for teaching practitioners and field workers about the clinical manifestations of famine and undernutrition, particularly with respect to the Global South. Current international guidelines for clinical photography are not consistently applied or enforced, which has led to violations of privacy and rights, particularly for patients and victims of disaster in the Global South. Combining existing clinical photography guidelines from the North with ongoing clinical ethics debates in the South, this paper explores approaches to establishing photography guidelines throughout the world that will be sensitive to the privacy and dignities of all patients and victims of emergencies.

IS IT ETHICAL TO STUDY WHAT OUGHT NOT TO HAPPEN?1

In the Democratic Republic of Congo, only an estimated 2% of all AIDS patients have access to treatment. As AIDS treatment access is scaled-up in the coming years, difficult rationing decisions will have to be made concerning who will come to gain access to this scarce medical resource. This article focuses on the position, expressed by representatives of Médecins sans Frontières (MSF), that the practice of AIDS treatment access rationing is fundamentally unethical because it conflicts with the ideal of universal treatment access and the human right to health. The conclusion is that MSF's position lacks coherence, has negative practical implications, and is unfair to governments struggling to increase patient's access to AIDS treatment in unfavorable circumstances.

Ethical codes in humanitarian emergencies: from practice to research?

Notable strides have been made in recent years to develop codes of conduct for humanitarian intervention in conflicts on the part of international NGOs and UN organisations. Yet engagement by the academic and broader research communities with humanitarian crises and ongoing complex political emergencies remains relatively ad hoc and unregulated beyond the basic ethical guidelines and norms developed within universities for research in general, and within the governing and representative bodies of particular academic disciplines. This paper draws on a case study of research on humanitarian assistance to Liberia during that country's civil war from 1989 to 1996. The difficulties faced by humanitarian agencies in Liberia led to the development of two key sets of ethical guidelines for humanitarian intervention: the Joint Policy of Operations (JPO) and Principles and Policies of Humanitarian Operations (PPHO). This paper seeks to address what lessons, if any, these ethical guidelines, together with different experiences of conducting research in war-torn Liberia, can provide in terms of the role of academic researchers--and research itself--in humanitarian crises.

Oceans of need in the desert: ethical issues identified while researching humanitarian agency response in Afghanistan

This paper describes the interventions by the International Committee of the Red Cross to support a hospital in Afghanistan during the mid 1990s. We present elements of the interventions introduced in Ghazni, Afghanistan, and consider a number of ethical issues stimulated by this analysis. Ethical challenges arise whenever humanitarian interventions to deal with complex political emergencies are undertaken: among those related to the case study presented are questions concerning: a) whether humanitarian support runs the risk of propping up repressive and irresponsible governments; b) whether humanitarian relief activities can legitimately focus on a narrow range of interventions, or need to broaden to address the range of challenges facing the health system; and c) whether sustainability and quality of care should be routinely considered in such settings. The paper concludes by highlighting the value of case studies, suggesting mechanisms for extending transparency and accountability in humanitarian health interventions, and highlighting the need of contextualising humanitarian work if the interventions are to be successful.

International obligation and human health: evolving policy responses to HIV/AIDS

The world is in the early stages of what will be the greatest health crisis since the advent of modern medical technologies. Millions of people—particularly people in many of the world's poor countries—are infected with HIV. The vast majority of these people will go without modern medical intervention or substantial treatment, and will rapidly develop AIDS. The extent of this problem presents profound moral and ethical questions for the world's wealthy people and countries, for it is they who are most able to assist the poor in managing and reversing this human tragedy.