Photo of participants in a small group discussion at the 2012 hhe forum

In November 2012, the humanitarian healthcare ethics (hhe) research group hosted the Humanitarian Healthcare Ethics Forum at McMaster University, in Hamilton, Ontario, Canada. Participants from a variety of disciplinary and organizational backgrounds engaged in an intensive deliberative forum on the development of realistic applications for ethics in humanitarian healthcare practice.

Participants included members of the World Health Organization (WHO), Médecins Sans Frontières (MSF, Canada, Sweden, and Switzerland), Red Cross Canada and the International Committee of the Red Cross (ICRC), as well as practitioners and academics from around the world. This forum, which resulted in the formation of HumEthNet, was supported by funding from the Canadian Institutes of Health Research (CIHR) and contributions from McMaster and McGill universities.

Summary of the Forum

Day 1

Day 1 set the stage for the work ahead. Participants introduced themselves and their expectations. Case narratives drawn from the original study on Ethics in situations of disaster and deprivation were read aloud, setting the empirical foundations of the subject of the Forum. Our aim was to highlight that there is a moral obligation to respond to the ethical challenges described by the respondents of the study and formulate a more systematic response for the broader needs in humanitarian healthcare ethics.

Day 2

Day 2 began with a number of presentations of initiatives aimed at better mapping the terrain of humanitarian healthcare ethics.

  • The McMaster/McGill team outlined the four origins of ethical challenges that emerged as core themes from their grounded theory analysis. The team also described the current Knowledge Translation projects that have emerged from the research, such as the humanitarianhealthethics.net web portal and the Humanitarian Healthcare Ethics Analysis Tool (HHEAT).
  • Dr Philippe Calain, who has been working towards developing a humanitarian healthcare ethics curriculum, gave a thoughtful presentation on the challenges of bringing ethics to this context. Dr Calain drew attention to the crucial distinction between moral distress and psychological distress, each of which may have overlapping presence but require different approaches to be properly addressed — a distinction which had not been adequately attended to in practice with negative consequences.
  • Dr Donal O’Mathuna presented on the European Union funded COST Action (IS1201) initiative, a research network examining disaster bioethics that will involve collaborations with European scholars, international humanitarian agencies and others over the next four years.
  • Dr Barry Pakes briefly presented a framework on public health ethics.

In the ensuing discussion, the following important question was raised: why do we need humanitarian health ethics (as opposed to, for example, medical or public health ethics)? It was clear that the reasons and justifications that support the inclusion and serious consideration of hhe ought not to be taken for granted, but made explicit. Concerns were put forward that ethics could become nothing more than window dressing, and there ought to be means of identifying ways to provide evidence that attending to ethical issues really can make a difference, and what such a difference would look like.

The consensus emerged that the chief reasons for incorporating hhe are:

  • to help respond to and support responders with the moral distress they encounter during missions. That this was in part to help them cope and learn strategies of self-care, but also very importantly,
  • to ensure better, more ethical, care, decision-making processes and programs for people in crisis and in need of healthcare interventions. In addition, there was agreement that
  • including ethics could increase credibility and help limit legal liabilities due to lack of preparation for making ethical decisions in extreme contexts.

Some focused discussion emerged about the functional value of moral distress as a signal that something needs our attention. General agreement emphasized that the ideal was not to get rid of functional moral distress, but to provide resources and support to help mitigate the dysfunctional effects that lead to serious negative consequences such as inaction, burnout and depletion of human resources for field missions.

The afternoon was spent in small group discussions of two questions:

  1. What are the ethical challenges of humanitarian healthcare practice?
  2. Where are the target opportunities for adding tools and/or other kinds of support for ethical humanitarian healthcare practice?

In response to Question 1, challenges emphasized included:

  • The risk of ethical imperialism: who is and should be setting humanitarian health ethics objectives? Ethics for whom?
  • While tools can be provided to deal with ethical challenges, practitioners may fail to perceive ethical problems.
  • Hero mentality can be part of hh culture making it difficult for individuals to recognize moral distress resulting from ethical challenges as anything but weakness.
  • There is no clear way of measuring ethical practice and its impacts, which may make it difficult to convince funders of its importance.
  • Focusing on individual decision-making and moral reasoning in the field implies that the ethical gaze of humanitarian healthcare is focused on the individual. This may limit commitments at the organizational level and/or downplay global inequalities.

In response to Question 2, ideas for improving ethical humanitarian healthcare practice in five broad categories included (see Appendix A for details):

  • Training
  • Field
  • Policies
  • Debriefing
  • Resources

These group discussions led to agreement on further questions for exploration: Where are we directing our ethical gaze? Is the intention of a humanitarian healthcare ethics research group about more than better preparing individual healthcare workers? If so, how so? Through what mechanisms? How might hhe become part of operational ethics?

It was concluded that in order to make and maintain a moral space for the practice of humanitarian healthcare ethics, ethical interventions must engage collaborative efforts with host communities. It is also, practical to identify in temporal terms opportunities for improving ethical practice (before, in, and following the field), and ethical reasoning. A commitment to hhe needs to be formalized throughout humanitarian healthcare projects and structures, recognizing that a temporal approach to improving ethical practice follows the individual and as such makes hhe an individual ethos.

Day 3

The final day revolved around practical matters. First, a consensus was reached about a “mission statement” for the community of practice as follows:

A community of practice committed to developing & using research, education, policy, and/or tools to address ethical challenges in humanitarian healthcare in order to reduce practitioners’ (responders?) moral distress and improve ethical practice and decision-making at multiple levels (points).

By practitioners we include members of teams of people involved in healthcare oriented responses in humanitarian interventions.

This is a working statement, so it is expected that it will evolve through further deliberations.

Finally, participants broke into three groups to discuss areas for further discussion and collaboration toward realizing the mission statement. Although it was acknowledged that the discussions could just as easily build around issues such as the ethical considerations of disability in humanitarian healthcare practice, it was decided that the three groups would revolve around (see Appendix B for details):

  1. Theoretical underpinnings for hhe
  2. Educational and case study initiatives for hhe
  3. Operational resources and policies for hhe

Each group defined a number of objectives for follow up. Those participants who are willing to continue discussions will work together to achieve these objectives over the next months, with the McMaster and McGill research teams acting as liaison to report on the progress of the various groups. It was agreed that participants were welcome to participate in as many of the future working groups in each of these three areas as they desire, but that for the sake of moving things forward we would divide into groups according to initial interests for the purposes of the forum.

A network for hhe was proposed and the McMaster/McGill facilitators will follow up with the participants for ideas of how to best construct and steer this. The humanitarianhealthethics.net website can act as a focal point for the network and we will assess how best to welcome involvement and use electronic communication techniques to inform members of the network activities. The question of a name for the network remains a puzzle. Network on HHE was suggested at the meeting (hhen being somewhat less than ideal).

A more specific goal coming out of the Forum was to review the notes and summaries from the HHE Forum to identify key research questions in order to articulate an hhe research agenda. An initial draft will be prepared by the McMaster/McGill team and then circulated to Forum participants for their input.

Appendix A:

Ideas for improving ethical humanitarian healthcare practice in five broad categories:

Training

  • Ethics should be seen as a core competency. Training and awareness in universities to attract and shape humanitarian workers and provide support was proposed (e.g., on-line curriculum certification).
  • Buddy system and mentoring
  • Highlighting that ethics at the core of humanitarian practice needs to be emphasized.
  • Reflexivity on values that are prioritized by different healthcare professionals may be important to consider. In training, think through examples of real case implications that ensue from emphasis on or lack of attention to certain values.
  • Demystifying expectations before departure and training practitioners to recognize differences between functional and dysfunctional moral distress.

Field

  • Leaders and facilitators as resource people for ethical dilemma and dialogue in the field
  • Peer mentorship (Humanitarian action is a formative experience. In the humanitarian world, there are a number of people who have a lot to share with others.)
  • Hotline with ethical expert
  • Access to a humanitarian ethicist/mentor while in the field, possibly through a hotline
  • Use of local role models, cultural broker-interpreter
  • Daily debriefing, perhaps with cultural broker, in order to prevent snowballing issues
  • Greater emphasis and structures within the field for team approach and working on ethical challenges through consensus

Policies

Preparation for ethical interaction ought to involve:

  • Local staff alongside expatriate staff and learning from local role models
  • Greater consultation with local healthcare professionals
  • Cultural broker/ cultural interpreter as part of healthcare team
  • Online space for discussing ethical issues (community of practice)
  • Highlighting that ethics at core of humanitarian practice needs to be emphasized
  • Leaders and facilitators in the field as resource people for ethical dilemma and dialogue in the field
  • End of mission forms
  • Establishing continuity in health care exit strategies

Debrief

  • Debriefing with an ethicist
  • Peer mentorship (Humanitarian action is a formative experience. In the humanitarian world, there are a number of people who have a lot to share with others.)
  • Reflexivity on values that are prioritized by different healthcare professionals in a team may be important to consider.

Resources

  • A resource for identifying the “symptomology” of an ethical issue
  • Tools such as the Humanitarian Healthcare Ethics Analysis Tool (HHEAT), biographies, novels, and songs were suggested as powerful vehicles for describing moral challenges and instigating reflection.

Appendix B:

Topics identified by the collaborative groups:

Theoretical underpinnings for hhe:

  • Theoretical underpinnings for hhe are mostly unknown. What is the moral grounding of hhe? Identify the ethics of, for and in humanitarianism (Kass). Is there a framework for hhe? Is hhe a thing?
  • Is hhe just a combination of public health ethics, global health ethics, international and clinical ethics, or is it other than all of these? Do these support hhe? (Barry’s thesis proposes that humanitarian ethics assumes that there is a duty to respond, global health ethics asks whether there is a duty to respond).
  • Theory can be used to demystify the essential concepts of hhe. What is humanitarianism? How does moral distress play a functional role and how can it be distinguished from psychological distress?
  • Identify new and existing principles for hhe, and how existing principles change their meaning (e.g., independence in war, independence from states or corporation; or identifying the value of outrage in hhe?)
  • Consider inviting John Pringle to post a summary of the section of his thesis that explores the nature of ‘humanitarianism’ and invite comment
  • Mainstream humanitarians need to differentiate role of responders with being witness to the sources of conflicts
  • Examine the social construction of humanitarianism like Foucault’s description of how movements become institutions
  • Expanding understanding of images of aid

Educational and case study initiatives for hhe:

  • Develop further case studies for workshops and to add to the hhe repository on the website
  • Develop a literature review on Core Competencies for hhe
  • Working collaboratively on disasters with COST
  • Consider publishing cases in a venue such as BioethiqueOnline as an opportunity for dissemination

Operational resources and policies for hhe:

  • Measurement considerations: Evaluation and measurement of ethics interventions (such as the HHEAT) in the field. Ethical decision-making in practice also relates to moral suffering. What is the impact of ethics? Could there be a study design? Focus on moral distress with self-evaluation?
  • Create a tool to collect information on how many times people are reporting ethical challenges during field operations, and whether they are accurate (more specific cases reported)
  • Develop operational strategies to promote ethical decision-making and mitigate moral distress
  • Draw distinctions between policy versus operational elements; policy linked more to theoretical underpinnings
  • How to link theory to practice — does this speak more to operational decision-making?
  • How do we create moral spaces in practice? What do they look like?
  • Definitional issues: what is a policy? Could be guidelines, codes of conduct, also a de facto way of working that might not be documented
  • Harmonization of policies: there are too many policies already. We need to start from the field to see what works and what doesn’t work (bottom-up approach). Are there stories/cases/experiences that can provide examples from the bottom-up (e.g., how teams have addressed ethical issues)?
  • Develop an open-ended survey (What training and structures were useful in the field? What works? What doesn’t work? What do they wish they had?)
  • Collect modalities of how ethics could be applied