Ethical Decision-Making in Humanitarian Health in Situations of Extreme Violence

Humanitarian health organizations face enormous ethical challenges in conducting their operations, particularly in situations of severe and persistent violence. We define ethical challenges broadly here to include situations where the best moral course of action could be unclear (e.g., when additional deliberation or analysis is necessary to define the right action), where it might not be possible to fully uphold all the moral values at stake (e.g., when a duty to avoid harm conflicts with the duty to serve all equally), where the moral course of action is clear but circumstances prevent one from taking it, or where there is no right answer but action is needed.

This project and this organizational handbook are the result of a collaboration by the Center for Public Health and Human Rights and the Center for Humanitarian Health at the Johns Hopkins Bloomberg School of Public Health, supported by individuals from the Johns Hopkins University Berman Institute of Bioethics, the Syrian American Medical Society (SAMS) and the International Rescue Committee (IRC). The project explored the ethical challenges organizations faced in situations of extreme violence in Syria, and, working from that context, sought to provide a framework of principles for ethical decision-making, as well as a handbook with practical guidance for humanitarian health organizations to resolve these complex ethical challenges.

 The handbook is organized so that, following this introduction, the second section presents a brief overview of the JHU/IRC/SAMS project on ethical challenges in humanitarian health in situations of extreme violence. This overview describes the methods of our study, and presents key findings from our systematic literature review, results from our interviews with organizational managers and front-line health workers, and a summary of discussions held in Gaziantep, Turkey and Amman, Jordan with organizations working on the humanitarian health response in Syria. The overview also presents the five key recommendations from the project, integrating results from the literature review, the interviews, and the workshops. These five recommendations (see below) are described in further detail in the third section, with a focus on how organizations might take steps to implement them.

 In the annexes, the handbook provides examples of four scenarios of ethical challenges that organizations might wish to use as part of their trainings on ethics and ethical decision-making. We also provide a series of worksheets for organizations to use in processing their ethical decision-making. We also provide a list of references and resources for further review.

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