Ethics and the closure of humanitarian healthcare projects

 

“While many project closures unfold smoothly, in other cases they are contested and give rise to ethically challenging situations for humanitarian organizations, their partners, and local communities.”

 

Context:

Non-governmental organizations routinely make and enact decisions to close humanitarian health projects. Doing so is unavoidable, and a necessary component of humanitarian action. However, ethical questions may arise related to why a project is selected to be closed and how closure is implemented. Moreover, these decisions, and the process and impact of closing projects, are likely to be perceived differently from the perspectives of those involved in and affected by them. Different models of closing projects have been utilized, including phasing down (gradually decreasing the project in size, sometimes leaving a small presence in place in case the project needs to be reactivated in the future), phasing over (gradually shifting it to local actors), handing over (transfer of the project to local actors), and ‘cut and run’ (sudden termination of a project). While many project closures unfold smoothly, in other cases they are contested and give rise to ethically challenging situations for humanitarian organizations, their partners, and local communities. Considerations include clarifying what is owed to communities with whom an organization has been working, the intrinsic as well as instrumental value of humanitarian projects, and the structured nature of health vulnerabilities during war, disaster or public health emergency. It is thus critical to examine the ethical implications of humanitarian project closure, and consider how closure can be accomplished in ways that take are consistent with ethical commitments including minimizing harm, being accountable, upholding impartiality, and demonstrating respect. 

Our work on this topic has included two studies (described in greater detail below):

Ethics of Closing Projects (ECP1) (2018-19): In this first study we conducted a scoping literature review, interviewed national and international humanitarian workers, and developed a guidance note on the topic of ethics and the closure of humanitarian health projects.

Ethics of Closing Projects (ECP2) (2020-23): Building on ECP1, we received funding to conduct ECP2. This grant has three interlinking phases: development of a conceptual framework, qualitative research in three communities in the Philippines where projects have been or are being closed, and development of resources related to project closure.


Ethics of Closing Projects (ECP1) (2018-19)

Our interdisciplinary research team (with expertise in global bioethics, political philosophy, humanitarian action, medicine, nursing, rehabilitation and qualitative research methods) worked collaboratively with our study partner, the non-governmental organization Médecins du Monde-Canada , to answer the following research question: What values and approaches support ‘ethical closure strategies’ when humanitarian organizations elect to close a project?

We used an integrated study design that combined qualitative interviews and a literature review, with normative ethical analysis in order to develop a set of ethics guidance notes about humanitarian project closure. This approach allowed us to work ‘up’ from experiences of individuals with first-hand experience of the phenomenon of interest* and to work ‘down’ from normative theories. The combination of these approaches supported the development of ethical guidance that is grounded in experience, and that is also informed and inspired by normative analysis. Our hope is that through this project we will spark further discussion and debate around this important topic within and across humanitarian organizations, and that the study outputs will support organizations as they make and implement decisions to close humanitarian projects.

* in ECP2, we are widening the perspectives that are included in our research through case studies in three communities in the Philippines where humanitarian projects have been closed.

Literature review:

As part of the project, we conducted a literature review of gray and academic sources. 

The review has been published in the International Journal of Humanitarian Action. It is available open-access from https://link.springer.com/article/10.1186/s41018-019-0064-9

The following document includes a list of all the articles that were selected for inclusion in the review: Ethics of closing humanitarian projects_scoping lit review_full reference list

Interviews with national and international humanitarian workers:

We conducted an exploratory qualitative study in which we interviewed national and international humanitarian workers. We identified features across the timeline of humanitarian projects (from the early design phase, to after a closure has occurred) that participants identified as important considerations for ‘closing well’, including: respectfully engaging with partners and stakeholders, planning responsively, communicating transparently, demonstrating care for local communities and staff during project closure, anticipating and acting to minimize harms, and attending to sustainability and project legacy.

The study has been published in the International Journal of Humanitarian Action. It is available open-access from https://jhumanitarianaction.springeropen.com/articles/10.1186/s41018-020-00082-4

Ethics guidance:

Based on the review of gray and academic literature, qualitative interviews, and wider reading in the areas of bioethics, humanitarian ethics, political philosophy and political science, we created a guidance note related to ethics and project closure. The guidance note was refined through a second round of interviews and during a feedback workshop. Based on these discussions, we elected to create two versions of the document (a condensed and extended version) and a one-pager that excerpted key questions. These documents are accessible here:

The team:

Matthew Hunt, Ryoa Chung, Lisa Eckenwiler, John Pringle, Nicole Pal and Shelley-Rose Hyppolite

Partner: Médecins du Monde-Canada

medecindumonde

Funding: RRSPQ Public Health Ethics Axis, 2018-19

images


Ethics of Closing Projects (ECP2) (2020-23)

Building on our previous research, we developed a second project with the goal of examining the topic of humanitarian project closure from the perspectives of people living in communities where projects have been or are being closed, as well as project partners. This study is entitled “A qualitative inquiry into the ethics of closing humanitarian projects in the Philippines, focusing on moral experiences of community stakeholders” and is based on a partnership with the Center for Disaster Preparedness based in Manila, the Philippines.

The project has three interconnecting phases: 1) development of a conceptual framework, 2) empirical research in three communities in the Philippines affected by disaster or conflict and where projects are being or have been closed, and 3) co-development of resources tailored for local communities and humanitarian organizations. 

Building a Conceptual Framework for ‘The Ethics of Closing Humanitarian Projects” 

Our second study on the ethics of project closure is focused on the moral experiences of community stakeholders in the Philippines. In preparation for collecting empirical data in the Philippines, we are beginning the study by developing an initial conceptual framework on the ethics of project closure (ECP) which will help to orient subsequent phases of the study.  

The idea is to construct a detailed conceptual framework to orient our work and help us understand in greater depth some of the conceptual terrain surrounding ECP. By expanding on concepts such as justice, solidarity, care, epistemic injustice, localization, and so on, we can have a better grasp of the implications of project closure and the moral experiences of community stakeholders. To observe how these concepts overlap and are interconnected with each other, we developed a concept map that permits us to explore the concepts of the ECP2 and how they can relate to each other.  

Thus, by visualizing some relevant concepts, we hope to illustrate the interconnections amongst key concepts in ways that can support analysis and reflection on ECP. The map illustrates a framing of ECP2 under the idea of ‘the ethics of the temporary’ and recognizes three core concepts (care, responsibility, and justice) alongside other key concepts that bear a relation to them. Below you can also find a list of relevant resources to further explore what they mean and their relevance to the ethics of humanitarian project closure. 

Ethics of the Temporar

Some Key References: 

 Care 

  • Richardson, HS (2012) ‘Moral Entanglements: Ad-hoc Intimacies and Ancillary Duties of Care. Journal of Moral Philosophy. 9(3). 376-409 
  • Robinson, F. (2011). The Ethics of Care: A Feminist Approach to Human Security. Temple University Press. 85-102.   

Responsibility 

  • Slim, H. (1997) Doing the Right Thing: Relief Agencies, Moral Dilemmas and Moral Responsibility in Political Emergencies and War. CENDEP Oxford Brookes University. 21(3) 
  • Heilinger, J.-C. (2021), Individual responsibility and global structural injustice: Toward an ethos of cosmopolitan responsibility. J Soc Philos. https://doi.org/10.1111/josp.12398 

Iatrogenic Harm & Therapeutic Domination 

  •  McFalls, L. (2010) Benevolent Dictatorship: the Formal Logic of Humanitarian Government, in Didier Fassin et Mariella Pandolfi (eds.), Contemporary States of Emergency : The Politics of Military and Humanitarian Interventions, New York. 317-334. 

Complicity Vs Being Implicated  

  • Greenfield D (2008) The Crime of Complicity in Genocide: How the International Criminal Tribunals for Rwanda and Yugoslavia Got It Wrong, and Why It Matters. Journal of Criminal Law and Criminology, Article 5 98(3):921-952 

Moral Entanglements  

  • Hunt, M., & Miao, J. (2017). Moral Entanglement and the Ethics of Closing Humanitarian Medical Aid Projects. Prehospital and Disaster Medicine, 32(S1), S47-S48. doi:10.1017/S1049023X17001376    
  • Ujewe, S (2019) Moral residue and health justice for the global south: addressing past issues through current interventions and research.Canadian Institute for Genomics and Society 

Imperfect Moral Contexts  

  • Tessman, L (2017). When Doing the Right Thing is Impossible. Oxford University Press.  
  • Bell, D & Carens, J. (2004). The Ethical Dilemmas of Human Rights and Humanitarian NGOs: Reflections on a Dialogue Between Practitioners and Theorists. Human Rights Quarterly 
  • Heilinger, JC (2021). Individual responsibility and global structural injustice: Toward an ethos of cosmopolitan responsibility. Journal of Social Philosophy. https://doi.org/10.1111/josp.12398 

Situating Closure in History  

  • Moore, T. (2013). Saving friends or saving strangers? Critical humanitarianism and the geopolitics of international law. Review of International Studies, 39(4), 925-947.  
  • Tyson, S. (2019) Carceral humanitarianism: Logics of refugee detention. Contemporary Political Theory 18, 83–86. https://doi.org/10.1057/s41296-017-0178-z 

Localization  

  • Accelerating Localisation through Partnerships (2019) Pathways to Localisation: A framework towards locally-led humanitarian response in partnership-based action. C. Schmalenbach with Christian Aid, CARE, Tearfund, ActionAid, CAFOD, Oxfam. 
  • GNDR (2019) Coherence Cookbook: Building Resilience in an Integrated Way. Global Network of Civil Society Organisations for Disaster Reductions.  
  •  Fast, L & Bennett, C (May 2020) From the Ground Up: It’s About Time for Local Humanitarian Action. Humanitarian Policy Group Report  

Procedural Justice/Fairness 

  • Heyse, L. (2013) Tragic Choices in Humanitarian Aid: A Framework of Organizational Determinants of NGO Decision-Making. International Society of Third-Sector Research. 
  • Fuller, L (2012). Priority-Setting in Non-Governmental Organizations: It is not as easy as ABCD. Journal of Global Health Ethics. 8:1, 5-17  
  • Hurst et al. (2009) Allocating Resources in Humanitarian Medicine. Public Health Ethics. 2(1) 89-99 
  • Fuller, L. (2006). Justified Commitments? Considering Resource Allocation and Fairness in Médecins Sans Frontieres-Holland. Developing World Bioethics. 6(2) 59-70 

Second-best Actor 

  • Rubinstein, J (2015), ‘Between Samaritans and States: the Political Ethics of Humanitarian INGO’s’  
  • Rubenstein, J. (2009), Humanitarian NGOs’ Duties of Justice. Journal of Social Philosophy, 40: 524-541. https://doi.org/10.1111/j.1467-9833.2009.01469.x 

Epistemic Injustice 

  • Fricker, M. (2009). Epistemic injustice: Power and the ethics of knowing. Oxford: Oxford University Press. 

Team: Matthew Hunt, Elyse Rafeala Conde, Lisa Eckenwiler,  Shelley-Rose Hyppolite, Mayfourth Luneta, John Pringle,  Lisa Schwartz

Partner: Center for Disaster Preparedness

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Funding: Social Sciences and Humanities Research Council 

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