Complicity, Entaglement and Being Implicated: The Double Effect of Humanitarian Healthcare Practice

by Lisa Schwartz

On the 4th and 5th of November 2013, Paul Bouvier of the International Committee of the Red Cross (ICRC) and Nicolas Tavaglione of the University of Geneva hosted a symposium called “From humanity to complicity? Ethical duties and dilemmas of humanitarian action in wars and armed conflicts” at the Fondation Brocher, in Hermance, Geneva, Switzerland. Those gathered included philosophers and legal scholars, and members of the ICRC and MSF. It was a productive mix of scholars, practitioners and policy makers that created a welcome space for discussion of ethical theories of complicity in humanitarian healthcare practice.

The event permitted analysis of the ways in which neutrality and independence are sometimes tested through the instrumentalization of aid agencies. Paul Bouvier framed the event by asking, “How can it be possible to do the work of humanitarian aid without abandoning humanitarian principles?”, which Nicolas Tavaglione illustrated with a pivotal example of providing care for amputation after Sharia punishment. Would it be better to refuse to treat or to provide the best treatment possible while feeling complicit in the amputation?

Highlights of the presentations helped identify the conceptual underpinnings of the legal and theoretical ethics of humanitarian practice, and what can be seen to be complicit with unethical actions of others. Chiara Lepora and her co-author Rob Goodin asked if it is possible to act during violence without becoming part of it. They described key features of ‘complicity’ highlighting most significantly that it includes awareness of and intent to comply with immoral actions of others. This raised the possibility of another concept where humanitarian aid workers become unwittingly entangled or accidentally implicated rather than acting intentionally.

Hugo Slim opened the session with an overview of his seminal work, and asked the critical question whether there is or ought to be a healthcare ethics of humanitarian practice or whether this opens us to humanitarian exceptionalism that ought not to be tolerated at the risk of compromising significant principles of health ethics. This is a key question for future projects, and proposals need to be articulated if there is agreement that the context demands specific moral direction. At its heart, Slim proposed that complicity must be attended to so that the moral integrity of the actor can stay in tact at a fundamental level.

Christopher Kutz examined the terminology of complicity, and drew attention to inadvertent complicity, as different from moral compromise. He added that good acts may include unintended bad consequences, such as cooperating with evil while building relationships necessary for access.

Daniel Messelken examined the duty to protect and provided critiques of military intervention. Messelken was among three speakers, including myself, to introduce the Doctrine of the Double Effect as a potential way to explore the problem of complicity. Larry May drew on Greek mythology and linked the discussion of guilt and complicity to the Oresteia. He argued that it is best not to look to individuals to assign blame but to the leadership who defined the mission. Liability should therefore be connected to what role you actually played, and mens rea and actus reas are split when leadership have guilty intent but the people doing the act have not planned the immoral action. Is there a limit to punishment, and can there be an acceptance of purification? If humanitarian work is heroic or supererogatory could punishment be suitably moderated, or can sacrifice such as moral distress be seen as sufficient?

Two presentations introduced qualitative data into the discussion. I presented findings from the hhe and EMMRG studies and explored some philosophical concepts such as Doctrine of Double Effect and entanglement, through the findings. Isabelle Delpla provided perspective of the recipient population from Srebrenica who she asserted would, rather than perceiving themselves as beneficiaries, resent the sense that they have been recipients of anything. She described how immunity of the UN led to humanitarian action being viewed with suspicion with hidden agendas not for the benefit of the victims. Though she added that recipients do trust and like individual care givers, they were suspicious of the aid organizations, and do not see that the organizations ought to be protected from accountability.

Lawyers for ICRC, Anne-Marie La Rosa and Jamie Williamson, proposed a paradigm shift in humanitarian work influenced by external factors, over which there is no control, forcing the organization to act in a specific way and becoming entangled or dragged into a specific engagement. Accountability could be operationalized to try to avoid complicity and warned that complicit humanitarian assistance, even if it could be described as ‘unlawful right action’, might fall under the criminal law.

Peter Schaber asked when humanitarian actions cease to be morally right if ever? Do they cease to be right by acts of complicity? Even if there is no intention to contribute, no shared purpose with immoral actors, and are aimed at the good? He proposed that individuals decide what each one can live with thus preserving their own integrity and dignity. This raised the question whether aid workers have permission to walk away simply because they cannot endorse an action or agenda? What about when there is no one there to take up the slack of you walk away? It is possible that reminding the wrong-doer of their wrong-doing, and minimizing as far as possible the harm of the wrong-doing would address the quandary?

Philippe Calain and Jean-Marc Biquet offered case analyses that enlivened the issues. They described how burn-out is a true liability for humanitarian healthcare providers repeatedly faced with impossible choices and asked to act against their professional codes of conduct. They concluded by proposing a move beyond heroic humanitarianism and an examination of the lack of dialogue and understanding with local professionals.

In May, Lisa Eckenwhiler and Matthew Hunt are collaborating with Brocher to present a smaller workshop on Ethics and Counter-terrorism.

Lisa Schwartz ( is co-director of the Humanitarian Health Ethics Research Group, McMaster University, Hamilton, Canada.

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