Putting an ethical dilemma into a narrative and analysing it. This is the exercise that the author skilfully undertakes in this article, which uses a real-life situation to explain the principles of operational ethics.
Democratic Republic of the Congo, 2006. Intense conflict is raging in the east of the country. A humanitarian organisation’s convoy is making its way to a zone beyond one of the many eastern fronts. Villagers in clear distress stop the convoy. A man implores the female team leader to come into a shack. She goes through the door and finds a woman squatting inside, moaning and bleeding profusely. The woman has just given birth. She is coughing, complaining and suffering. She has a very high fever. The team leader is not a doctor and there are no healthcare workers on her team. They call a sister NGO, a medical organisation, which helps them better understand the situation’s level of urgency: it is a life-threatening emergency. Time is ticking. A decision must be made quickly. Yet the convoy vehicles do not have any suitable material on board – not even a stretcher – and the workers have no personal protective equipment: no gloves, overalls, or face masks.
Should they transport the patient in her current state, and seated, which would be a very painful position, and expose the team to the risk of catching tuberculosis or HIV through splatters of blood? Or should they work with the medical NGO to coordinate medical attention that would arrive later, but would be better suited to the situation?
Dilemmas and questions
This is the kind of dilemma that humanitarian workers often face. Memories of such situations are engraved in colleagues’ minds. These situations are the focus of their decision-making. Yet when you think about humanitarian ethics, such dilemmas and questions are not what first come to mind. The risk of humanitarian aid being misused or embezzled is the issue that gets brought up most often.
The story above is given to illustrate the imbalance between those providing care and those being cared for: an imbalance that humanitarian professionals face in their operations on the ground. There are major risks in this imbalance. The ethics of intervention tackles these risks with the notion of distance, with attempts at discernment and with regulation of individual and organisational approaches.
How do professionals in this sector understand humanitarian ethics? What support do they receive in carrying out their operations? How are humanitarian ethics considered? Is it (only) a matter of securing enough resources to tackle dire situations? Is it about being exemplary, even irreproachable, out of duty, during operations on the ground? Are humanitarian ethics an aim to be reached? Or is it more about endless questions about what is right and best in a concrete case at a particular time, in a particular context, for a particular action? Are humanitarian ethics an overarching framework that is fully structured with principles and that the sector recognises? Or is it a case-by-case approach that results in the best possible – or least worst – decision-making on a daily basis? Lastly, are humanitarian ethics specific? Can the nature of humanitarian ethics be identified precisely? Or is it simply the sum of the rules of professional conduct for each line of work in an NGO (doctors, nurses, physiotherapists, civil engineers, etc.)?
Research time is needed, first to address the ethical dimension of humanitarian work and the preoccupations[1]Céline Bareil, Gérer le volet humain du changement, Éditions Transcontinental, 2004. The notion of preoccupation as a part of analysis is borrowed from this work. of professionals in the sector and, second, to describe these professionals’ relation to the norm. Such research would have to borrow from a multitude of fields (ethics, sociology of organisations, social and clinical psychology, history, moral philosophy, etc.) and form a specific subject of study. But that is not the aim of this article. This article is an account. It is shared by a practitioner who has, over the course of her career, faced the ethical issues that arise in the medical and social sectors, in the defence of human rights, in psychiatry, in courts of law and, of course, in humanitarian work.
Principled or concrete ethics?
Saying that a humanitarian commitment reflects a unique attachment to the values of humanity and justice would be simply tautological if the foundations and pathways of humanitarian professionals had not been examined in detail at the start of the 2000s. This research, full of lessons for us, revealed that an attachment to otherness and the ideal of justice was not only central in humanitarian workers’ relation to their profession, but that in their pathways there were more personal markers, including biographical breaks with the past and specific conditions of socialisation.[2]Pascal Dauvin et Johanna Siméant, Le travail humanitaire : les acteurs des ONG, du siège au terrain, Presses de Sciences Po, 2002.
Though the sociology of humanitarian organisations has probably evolved since the publication of the reference work by Pascal Dauvin and Johanna Siméant, memories inside organisations remain intact. For example, the memory of a refusal, a moment of outrage or an ethical clash, as a founding event that engendered a given NGO, has been preserved and passed on. Such founding moments are often mythologised.[3]Rony Brauman, « MSF et le CICR, questions de principes », Revue Internationale de la Croix-Rouge, vol. 94, n° 888, 2012, p. 345-357.
“When we try to identify the ethical issues that our colleagues face we struggle to freely find words for what could have possibly brought about dilemmas or ethical risks in their work.”
Literature on humanitarian ethics touches upon an attachment to fundamental principles that structure humanitarian operations and that are actually the principles of the Red Cross Movement: humanity, impartiality, neutrality, independence, voluntary service, universality and unity. Four of these principles form, at the very least, a benchmark, if not a veritable consensus. They are humanity, which takes precedence, neutrality, which is an often-unloved younger sister, impartiality and, lastly, independence.[4]Code of Conduct for the International Red Cross and Red Crescent Movement and NGOs in Disaster Relief, 1994. These four principles form cardinal points and ways of working. In a single sweep, they help respond to issues of meaning, desirability and fairness, and they equip practitioners once and for all. This is so deeply true that when we try to identify the ethical issues that our colleagues face we struggle to freely find words for what could have possibly brought about dilemmas or ethical risks in their work. Does this mean that practitioners do not ask themselves questions about the meaning of their acts, about responsibility in their actions, about the potentially perverse – or, on the contrary, deliberate – effects that their operations have on others, on their organisation and on themselves? Of course not.
Inside humanitarian organisations, questions go hand in hand with action and form the subject of many discussions, if not the memories – sometimes painful ones – that many colleagues have. Yet everything unfolds as if the principles and the refrain “first, do no harm” were performative and clearly conclusive. Despite this, something persists. And that “something” is the need to adjudicate, and therefore yield, in contexts of dignity being violated, of humans inflicting violence upon other humans and of law struggling to serve as a sufficiently protective norm. What can be done with this huge, yet derisory, power of initiative and decision-making? How can it be best used? Colleagues will tell you that this is the preoccupation that agitates them.
To take this preoccupation into consideration – without magical thinking nor circumvention – you have to touch upon the memories of ethical clashes that professionals have encountered, you have to bring together values and norms, and you have to collectively reestablish a framework, including a theoretical one, for deliberation. In this way, in our own training of our colleagues, before we try to support new developments, we look at the continuum between law and ethics and we underline the fact that behind a norm (whether a social norm, a legal norm or a rule of professional conduct), there are, as the very essence of ethics, fundamental values that are protected. These values are the positive expression of major fundamental prohibitions that are part of traditions and conventions (for morality), part of texts and practices (for legal norms and professional conduct) and part of thought development (for ethics). So, in training courses, we are used to saying that whereas the law (and its relative, professional conduct) prescribes or prohibits, morality condemns or praises, while ethics call into question and try to offer answers. Hence, there is, first, the law (including codified law in the major instruments of international human rights law and international humanitarian law), which aims to protect human dignity (a sanctuary), to which rules of professional conduct, especially in medicine, are added, with the following prescription in the form of a prohibition: “First, do no harm”.[5]This is doubtless important in organisations founded more often by medical staff or rescuers than by legal experts. Yet law, however normative it is, and professional conduct do not exhaust all ethical questioning.
So, the sector’s four principles that we underlined above are derived as much from medical ethics as from principles of international law, including international humanitarian law. You just have to reread the Hippocratic Oath to be convinced about this. For these reasons, there is no opposition between corpora and abstract ethics (ethics of lofty principles), which is contrasted with concrete ethics.
Supporting the sector’s professionals in their ethical reasoning
Professionals are invited to follow this pathway that leads from law to professional conduct (morality being put aside here), and which takes you to humanitarian ethics, when they have to weigh up the legitimacy, purpose and soundness of a decision. This is our main aim when we have to equip practitioners in our work: it is about reminding them of the vast legacy that humanitarian ethics preserve and of the link between the sector’s principles and universally recognised legal norms. Indeed, it is about referring to principled ethics as a basis that helps us make our way towards concrete, operational ethics: the field of decision-making. And for that, you have to name things. Are there “ethical conflicts” within the team (tensions between values or an individual ethos and expectations from the organisation and team)? Is the team facing a “dilemma” between two options that are equally unsatisfactory ethically in the face of a pressing need to make a decision? Is the team facing risks – potential or real, identified or concealed – that could undermine the organisation’s values or the sector’s principles?
“It is about referring to principled ethics as a basis that helps us make our way towards concrete, operational ethics: the field of decision-making.”
Once this diagnosis has been given in a collective framework, support can begin and a pathway can be made towards a possible resolution or towards a strategy applied to reduce or cancel out risks as much as possible. These are tools and methodologies that aim to cast light as decisions are made – in short, a vade mecum. At the end of this process, one of the essential components of ethical decision-making will have been applied: collegiality. The colleagues involved will have experienced, together, a capacity for doubt and reasoning.
As regards the dilemma, the decision envisaged will then be assessed in light of three criteria:[6]Yves Boisvert, « Le processus de délibération éthique », in Yves Boisvert (dir.), Petit manuel d’éthique appliquée à la gestion publique, Éditions Liber, 2003, p. 81-92.
- -its replicable nature: is it only a specific case – an exceptional exception – or could the decision, despite having been difficult to make, be recommended for other circumstances?
- its communicable nature: could the decision be publicly justified, if need be?
- its reciprocal nature: if the decision that you are about to make and that has effects on others was made by someone other than yourself but had an effect on you, would you still find it fair?
These three criteria, taken together, serve as a body of evidence that confirms whether the dilemma has been resolved, either perfectly or in the least worst way possible.
The reader will doubtless rightly wonder – especially if they have worked in contexts and tackled situations where decisions are made quickly and urgently – how a humanitarian worker could possibly find enough time to ask themself questions so methodically. In reality, in the background, it is about rising to the challenge of developing an “ethical culture” based on processes and methods, which allows for collegiality, trust and deferred decision-making through mechanisms – mechanisms with analytical independence that is protected by and for the organisation. This ethical culture is well known in the medical and social sector, yet it also exists in humanitarian organisations that have a committee of applied ethics or that have, like Humanity & Inclusion does, several ethical entities inside its organisational structure, including its entity dedicated to operational ethics: the Institut d’éthique opérationnelle. The existence of these mechanisms and support for the development of an ethical culture make it possible for questions to be asked and for answers to be given, compulsorily and in the best way possible. In our everyday work at the Institut d’éthique opérationnelle at Humanity & Inclusion, we are both witnesses of this approach and active players in it.
An epilogue
The woman who had just given birth in the story told at the start of this article had a particularly serious medical condition. Ultimately, the sister NGO transferred this woman, but she died shortly after she arrived at the hospital on the other side of the front. She had suffered severe blood loss. The team leader asked a surgeon at her organisation’s head office about her decision, to check that she had made the right one. The surgeon told her that she had indeed made the right decision. Yet 18 years later, doubts remain – even as these words are being written here, and even if the decision was perhaps a sensible one.
“There is a need to create preserved spaces dedicated to dialogue that are not only reserved for ethical alerts but are also conducive to fruitful discussions.”
Since then, our work on the ground has convinced us that it is not always possible to respond definitively and optimally – can we dare say “satisfactorily”? – to this kind of dilemma. But our work has also taught us that it is easier to understand such dilemmas and to manage them, metabolise them and question them when an ethical culture is promoted within an organisation. This ethical culture makes it easier to put a situation into perspective, to ask questions and, ultimately, to support professionals. We therefore believe that it is vital to create the conditions for this ethical culture to emerge and to make it long-lasting through suitable ethical entities inside organisations and through appropriate training courses given. There is a need to create preserved spaces dedicated to dialogue that are not only reserved for ethical alerts but are also conducive to fruitful discussions. The challenge is important for the sector’s organisations and for the populations and professionals who could be spared a little suffering and ethical exhaustion – a subject that deserves special attention in care professions. In return, we gain congruence: effective application of principles and our values. We also gain a closer relationship with the very meaning of our profession.
