What do we need to know to assess the issue?
The second step of the HHEAT highlights three specific data gathering categories:
- Resource Allocation and Clinical Features
- Participation, Perspectives and Power
- Community, Projects and Policies
These categories reflect various domains of information that are especially relevant when deliberating on ethical issues in humanitarian healthcare contexts.
Resource Allocation and Clinical Features
If the ethical issue relates to the care of a specific patient, the relevant clinical features of the case should be explored. It is important to consider the diagnosis, all possible treatment options, and the risks, benefits and prognosis associated with each treatment option. Patient and family perceptions and values surrounding goals of care must be established. Instances in which duties to the individual patient conflict with larger public health goals deserve special consideration.
The fair distribution of scarce resources is an important and frequently encountered issue in humanitarian healthcare, where the severity and magnitude of need may be coupled with inadequate or insufficient resources. In one qualitative study, a humanitarian worker described how the team’s only oxygen machine generated “100 ethical discussions”. Analogous situations are commonplace. Determining what resources are available, how resources ought to be allocated, and how resource limitations should be approached in the short and long term merits considerable attention and may demand critical thinking and a creative approach.
Participation, Perspectives and Power
Humanitarian healthcare aid occurs in contexts where socio-economic inequalities, exploitative commercial industries, colonial histories, and violence between social groups or between nations operate on a variety of levels. Humanitarian workers often report feeling moral distress and ethical tension when confronted with situations arising in these challenging contexts. For instance, healthcare workers have reported feeling distress when confronted by gender inequality; and unfair differences in the treatment of national and expatriate staff with regards to the division of labour, remuneration and security. Being attentive to the perspectives of different stakeholders as well as the degree to which these perspectives are included in decision making is important. In addition, attention to power dynamics related to the issue may help generate a clearer understanding of features underpinning an ethical decision, which might otherwise remain hidden.
To promote inclusion of these perspectives, all relevant stakeholders should be invited to participate in ethical deliberations. At the very least, rationales for who is included in discussions should be carefully considered and justified. In addition, there may be colleagues within the organization, perhaps in a neighbouring project or at headquarters, who can provide insight into the issue. When considering seeking outside input, considerations related to confidentiality should be carefully evaluated. In addition, it is pertinent to question how cultural frameworks and personal and collective histories affect how an issue is understood.
Community, Projects and Policies
Organizational policies, project mandates and community characteristics impact ethical decisions. These influences should be clarified. For instance, healthcare professionals are part of a medical community, and norms surrounding professional hierarchies, roles and interactions may be different in humanitarian contexts. However, health professionals providing aid in humanitarian crises might consider performing clinical tasks that would exceed scope of practice due to a lack of human resources, a scenario raising legal and ethical concerns.
Exploring how community features and values align with project policies, goals and procedures is also an important source of information. Project mandates may not always fit perfectly with the needs of a community, raising concerns about the quality and types of care being provided; for instance, vertical programs may be excellent at targeting a specific disease, while failing to adequately address other pressing health needs in the population. Coordination and communication between humanitarian actors can also impact the quality and comprehensiveness of care provided. Further considerations include: the impact of staff turnover, organizational culture, clarity of program and organizational objectives and policies, and structures of accountability and responsibility.
More detail can be found on pages 15-18 of the HHEAT Handbook.
Return to HHEAT Handbook at a Glance.