BackgroundHumanitarian crises and emergencies, events often marked by high mortality, have until recently excluded palliative care—a specialty focusing on supporting people with serious or terminal illness or those nearing death. In the COVID-19 pandemic, palliative care has received unprecedented levels of societal attention. Unfortunately, this has not been enough to prevent patients dying alone, relatives not being able to say goodbye and palliative care being used instead of intensive care due to resource limitations. Yet global guidance was available. In 2018, (...) the WHO released a guide on‘Integrating palliative care and symptom relief into the response to humanitarian emergencies and crises’—the first guidance on the topic by an international body.AimsThis paper argues that while a landmark document, the WHO guide took a narrowly clinical bioethics perspective and missed crucial moral dilemmas. We argue for adding a population-level bioethics lens, which draws forth complex moral dilemmas arising from the fact that groups having differential innate and acquired resources in the context of social and historical determinants of health. We discuss dilemmas concerning: limitations of material and human resources; patient prioritisation; euthanasia; and legacy inequalities, discrimination and power imbalances.ImplicationsIn parts of the world where opportunity for preparation still exists, and as countries emerge from COVID-19, planners must consider care for the dying. Immediate steps to support better resolutions to ethical dilemmas of the provision of palliative care in humanitarian and emergency contexts will require honest debate; concerted research effort; and international, national and local ethical guidance. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Full Collection of Personal NarrativesZohar Lederman, Ola Ziara, Rachel Coghlan, Oksana Sulaieva, Anna Shcherbakova, Oleksandr Dudin, Vladyslava Kachkovska, Iryna Dudchenko, Anna Kovchun, Lyudmyla Prystupa, Yuliya Nogovitsyna, Ghaiath Hussein, Kathryn Fausch, P. P. Kyaw, Ayesha Ahmad, Richard W Sams II, Handreen Mohammed Saeed, Artem Riga, Ryan C. Maves, Elizabeth Dotsenko, Irina Deyneka, Eva V. Regel, and Vita Voloshchuk• An Unsettling Affair• How We Keep Caring While Walking Through Our Pain• (...) Adjusting Laboratory Practices to the Challenges of Wartime• Why We Stay• A Semi-Personal Story from a Ukrainian NGO Professional (or a Semi-Professional Story from a Ukrainian Person) Living through the War• When Ethics Survives Where People Do Not: A Story From Darfur• Burma’s Healthcare Under Fire: My Experience as an Exiled Medical Professional• When a Conflict Collapses on a Child: An (Aborted) Medical Evacuation of a Hazara Toddler During the Kabul Airport Blast and the Taliban Takeover• The Vagaries and Vicissitudes of War• Providing Care to a Potential Aggressor: An Ethical Dilemma• One Surgeon’s Experience During Armed Conflict in Ukraine• The Limits of Our Obligations• A Liberating Breath• Soldiers of the Invisible Front: How Ukrainian Therapists Are Fighting for the Mental Health of the Nation Under Fire• Stories of Families with Chronically Ill Pediatric Patients during the War in UkraineCopyright © 2023 Johns Hopkins University Press... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:How We Keep Caring While Walking Through Our PainOla Ziara and Rachel CoghlanAuthor Dedication. To my dear brother Omar Ziara, a bright doctor, entrepreneur, and community advocate who was killed in an Israeli bombing in November 2023.May your soul rest in peace and may your memory remain alive in our hearts. May your unborn child grow up to become the wonderful man that you were. Forever loved by all.Palestinian-American (...) poet, Suheir Hammad, writes:Occupation means that every day you die, and the world watches in silence. As if your death was nothing, as if you were a stone falling in the earth, water falling over water.And if you face all of this death and indifference and keep your humanity, and your love and your dignity and you refuse to surrender to their terror, then you know something of the courage that is Palestine.I am a doctor from the Gaza Strip in Palestine. I live through acute war and protracted occupation. I work under missiles and through scant resources. I experience risks and dangers and face abominable choices made from nightmares. I know heartbreaking death.As doctors here, we fear, suffer, cry, and grieve alongside our patients and their families. This is my story of how we continue to care.Summer 2014 A Fifty-Two-Day War: How To Stay And How To Keep Them SafeThe huge bombardment strikes close to the hospital, scattering glass and rubble. It brings an abrupt end to my rare, quiet pause for coffee. Are the babies hit? We sprint to the Neonatal Intensive Care Unit, our full attention only on those infants, hastily checking every crib. My thoughts are frenzied. What if the next missile strikes us? Will I be able to rescue them? Will I have time to carry their tiny bodies outside through wreckage and fire? How will I choose who to save, and who to leave behind? Could I choose? Will I even be able to think lucidly, act logically for those babies if the fire consumes us? We stay.Somewhere, a house razed to the ground, a mother and her children dead. This time, our babies are safe.Summer 2014 A Fifty-Two-Day War: How To Cast Off Danger And How To Find ConsolationA missile shatters our neighbour’s roof. I am about to leave home for my evening shift. I check on my shaking mum; she is okay, not hurt at least. I ring the senior doctor. I am sorry. I am coming. I will be a little late. Two further missiles hit, wiping out the next-door building completely. No, do not send an ambulance for me. It is too dangerous. I will come [End Page 153] alone. Trembling through the dust and darkness, I leave on foot to reach those babies. I must compose myself. We are needed there to bring calm, to keep caring.And we gamble our lives to seek distraction and comfort for ourselves. We find solace through unbearable pain in our caring.Winter, Spring, Autumn, Summer, Any Day: How To Question Purpose And How To Feel HelplessIt is an ordinary night shift in ‘quiet’ times. Tonight, all the beds are occupied. All the ventilators are taken, forcing life into small, sick faces. At dawn, the phone call comes. A new baby struggling to breathe is on his way. I call around. No more beds to take him here or anywhere. No more ventilators—here or anywhere. Bring him here. We will care for him.He is in a very bad way. He needs immediate life-saving care. We take turns manually ventilating him, working to the hissing rhythm of the Ambu Bag1—inflating, deflating, inflating. Our arms ache. We keep pumping the bag. Do not stop. The moment when the morning shift arrives is our moment of salvage. We can go home. We have made it through the night without medicines, machines, disposables, or enough manpower, our arms throbbing. We have kept him alive.But he is so fragile, the system is fragile, we are fragile. Dare I even ask—is it worth it? Is it worth a baby surviving the... (shrink)