The need for professionals to volunteer their time in crisis situations and to reach across time and culture in the service of humanitarian interventions will likely not abate in the near future. This article provides readers with multiple venues for considering the ethical dimensions present in crisis and humanitarian interventions. Core ethical concerns common to helping situations are magnified in crisis work. In addition, issues unique to the nature of volunteer and crisis work must also be considered. Using hypothetical case (...) examples, bioethical principles, and ethical decision-making models, helping professionals are encouraged to go beyond their particular ethical codes in contemplating ethically and clinically sensitive volunteering. (shrink)

Médecins Sans Frontières (MSF) is an independent medical humanitarian organisation working in over 70 countries. It has provided medical assistance for over 35 years to populations vulnerable through conflict, disease and inadequate health systems. Medical ethics define the starting point of the relationship between medical staff and patients. The ethics of humanitarian interventions and of research in conflict settings are much debated. However, less is known about the ethical dilemmas faced by medical humanitarian staff in their daily work. Ethical dilemmas (...) can be intensified in humanitarian contexts by insecure environments, lack of optimum care, language barriers, potentially heightened power discrepancies between care providers and patients, differing cultural values and perceptions of patients, communities and medical staff. Time constraints, stressful conditions and lack of familiarity with ethical frameworks can prevent reflection on these dilemmas, as can frustration that such reflection does not necessarily provide instant solutions. Lack of reflection, however, can be distressing for medical practitioners and can reduce the quality of care. Ethical reflection has a central role in MSF, and the organisation uses ethical frameworks to help with clinical and programmatic decisions as well as in deliberations over operational research. We illustrate and discuss some real ethical dilemmas facing MSF teams. Only by sharing and seeking guidance can MSF and similar actors make more thoughtful and appropriate decisions. Our aim in sharing these cases is to invite discussion and dialogue in the wider medical community working in crisis, conflict or with severe resource limitations. (shrink)

Medical student and resident participation in global health experiences (GHEs) has significantly increased over the last decade. In response to growing student interest and the proven impact of such experiences on the education and career decisions of resident physicians, many medical schools have begun to establish programmes dedicated to global health education. For the innumerable benefits of GHEs, it is important to note that medical students have the potential to do more harm than good in these settings when they exceed (...) their actual capabilities as physicians-in-training. While medical training programmes are beginning to provide students with the knowledge to put their GHEs in context, they must remember that they also bear the responsibility of training their students in a framework to approach these experiences in a principled and professional way. It is necessary that these institutions provide adequate and formalised preparation for both clinical and ethical challenges of working in resource-poor settings. This paper outlines potential benefits and risks of GHEs and delineates recommendations to some of the current issues. (shrink)

Humanitarian health care practitioners working outside familiar settings, and without familiar supports, encounter ethical challenges both familiar and distinct. The ethical guidance they rely upon ought to reflect this. Using data from empirical studies, we explore the strengths and weaknesses of two ethical models that could serve as resources for understanding ethical challenges in humanitarian health care: clinical ethics and public health ethics. The qualitative interviews demonstrate the degree to which traditional teaching and values of clinical health ethics seem insufficient (...) for addressing all the realities of health care practice during humanitarian missions. They equally suggest that greater good orientations of public health ethics can thwart the best intentions of health care professionals wanting to attend to the interests of individual patients. Even though neither is complete on its own for helping guide health professionals on field missions, taken together these models have much to offer. At the same time, the narratives of the humanitarian health care workers illustrate how some of the crucial differences between public health ethics and clinical ethics generate tensions in humanitarian health practice. We offer an analysis of some of the complexities this creates for humanitarian health care ethics, and consider ways of adjudicating between the two models. (shrink)

In 1999, Médecins Sans Frontières set out to explore and demonstrate the feasibility of preventing and treating HIV/AIDS in a so-called resource-poor, economically and socially disadvantaged setting. The first MSF mission to incorporate antiretroviral treatment into its HIV-AIDS-oriented medical program was undertaken in Bangkok. The second project was launched in Khayelitsha where MSF has been providing ARV treatment for persons with HIV/AIDS since May 2001. Khayelitsha is an enclave of some 500,000 inhabitants, most of whom live in corrugated-iron shacks, without (...) running water or electricity. Unemployment is extremely high; crime and violence are rampant. The general prevalence of HIV/AIDS is 26%, measured among pregnant women. The tuberculosis incidence rate is one of the world's highest for open-space sites. Unsurprisingly, TB/HIV coinfection is very high too: 63% of those with TB are also infected with HIV. (shrink)

This paper, which is based on an extensive analysis of the literature, gives a brief overview of the main ways in which solidarity has been employed in bioethical writings in the last two decades. As the vagueness of the term has been one of the main targets of critique, we propose a new approach to defining solidarity, identifying it primarily as a practice enacted at the interpersonal, communal, and contractual/legal levels. Our three-tier model of solidarity can also help to explain (...) the way in which crises of solidarity can occur, notably when formal solidaristic arrangements continue to exist despite ‘lower tiers’ of solidarity practices at inter-personal and communal levels having ‘broken away’. We hope that this contribution to the growing debate on the potential for the value of solidarity to help tackle issues in bioethics and beyond, will stimulate further discussion involving both conceptual and empirically informed perspectives. (shrink)

As a result of increased interest in global health, more and more medical students and trainees from the.

Surgery is an important part of health care worldwide. Without access to surgical treatments, morbidity and mortality increase. Access to surgical treatment is a significant problem in global public health because surgical services are not equally distributed in the world. There is a disproportionate scarcity of surgical access in low-income countries. There are many charitable organizations around the world that sponsor surgical missions to under served nations. One such organization is Operation Smile International, a group with which both authors have (...) volunteered. This paper will describe the purpose and processes involved in Operation Smile and identify some of the key ethical issues that arise in short term medical volunteer work highlighting the importance of sustainability. (shrink)

This paper describes the interventions by the International Committee of the Red Cross to support a hospital in Afghanistan during the mid 1990s. We present elements of the interventions introduced in Ghazni, Afghanistan, and consider a number of ethical issues stimulated by this analysis. Ethical challenges arise whenever humanitarian interventions to deal with complex political emergencies are undertaken: among those related to the case study presented are questions concerning: a) whether humanitarian support runs the risk of propping up repressive and (...) irresponsible governments; b) whether humanitarian relief activities can legitimately focus on a narrow range of interventions, or need to broaden to address the range of challenges facing the health system; and c) whether sustainability and quality of care should be routinely considered in such settings. The paper concludes by highlighting the value of case studies, suggesting mechanisms for extending transparency and accountability in humanitarian health interventions, and highlighting the need of contextualising humanitarian work if the interventions are to be successful. (shrink)

This paper describes the interventions by the International Committee of the Red Cross to support a hospital in Afghanistan during the mid–1990s. We present elements of the interventions introduced in Ghazni, Afghanistan, and consider a number of ethical issues stimulated by this analysis. Ethical challenges arise wherever humanitarian interventions to deal with complex political emergencies are undertaken: among those related to the case study presented are questions concerning: a) whether humanitarian support runs the risk of propping up repressive and irresponsible (...) governments; b) whether humanitarian relief activities can legitimately focus on a narrow range of interventions, or need to broaden to address the range of challenges facing the health system; and c) whether sustainability and quality of care should be routinely considered in such settings. The paper concludes by highlighting the value of case studies, suggesting mechanisms for extending transparency and accountability in humanitarian health interventions, and highlighting the need for contextualising humanitarian work if the interventions are to be successful. (shrink)

Through its adoption of the biomedical model of disease which promotes medical individualism and its reliance on the individual-based anthropology, mainstream bioethics has predominantly focused on respect for autonomy in the clinical setting and respect for person in the research site, emphasizing self-determination and freedom of choice. However, the emphasis on the individual has often led to moral vacuum, exaggeration of human agency, and a thin (liberal?) conception of justice. Applied to resource-poor countries and communities within developed countries, autonomy-based bioethics (...) fails to address the root causes of diseases and public health crises with which individuals or communities are confronted. A sociological explanation of disease causation is needed to broaden principles of biomedical ethics and provides a renewed understanding of disease, freedom, medical practice, patient-physician relationship, risk and benefit of research and treatment, research priorities, and health policy. (shrink)

Theoretical and empirical research in bioethics frequently focuses on ethical dilemmas or problems. This paper draws on anthropological and phenomenological sources to develop an alternative framework for bioethical enquiry that allows examination of a broader range of how the moral is experienced in the everyday lives of individuals and groups. Our account of moral experience is subjective and hermeneutic. We define moral experience as “Encompassing a person's sense that values that he or she deem important are being realised or thwarted (...) in everyday life. This includes a person's interpretations of a lived encounter, or a set of lived encounters, that fall on spectrums of right-wrong, good-bad or just-unjust”. In our conceptualisation, moral experience is not limited to situations that are heavily freighted with ethically-troubling ramifications or are sources of debate and disagreement. Important aspects of moral experience are played out in mundane and everyday settings. Moral experience provides a research framework, the scope of which extends beyond the evaluation of ethical dilemmas, processes of moral justification and decision-making, and moral distress. This broad research focus is consistent with views expressed by commentators within and beyond bioethics who have called for deeper and more sustained attention in bioethics scholarship to a wider set of concerns, experiences and issues that better captures what is ethically at stake for individuals and communities. In this paper we present our conceptualisation of moral experience, articulate its epistemological and ontological foundations and discuss opportunities for empirical bioethics research using this framework. (shrink)

Health professionals are involved in humanitarian assistance and development work in many regions of the world. They participate in primary health care, immunization campaigns, clinic- and hospital-based care, rehabilitation and feeding programs. In the course of this work, clinicians are frequently exposed to complex ethical issues. This paper examines how health workers experience ethics in the course of humanitarian assistance and development work. A qualitative study was conducted to consider this question. Five core themes emerged from the data, including: tension (...) between respecting local customs and imposing values; obstacles to providing adequate care; differing understandings of health and illness; questions of identity for health workers; and issues of trust and distrust. Recommendations are made for organizational strategies that could help aid agencies support and equip their staff as they respond to ethical issues. (shrink)

One of the ways in which transnational medical agencies (TMAs) such as Medicins Sans Frontieres aim to increase the access of the global poor to health services is by supplying medical aid to people who need it in developing countries. The moral imperative supporting such work is clear enough, but a variety of factors can make such work difficult. One of those factors is the wrongdoing of other agents and agencies. For as a result of such wrongdoing, the attempt to (...) supply medical aid can sometimes lead to significant negative effects. What should TMAs do in such situations? On one view, TMAs should take account of any negative effects arising from the wrongdoing of others in just the same way in which they take account of negative effects arising more directly from their own actions, or from natural forces. To many people, this view seems wrong. In this paper, I articulate and discuss several different reasons why one might think this. In doing so, I hope to contribute to a debate about the more general question of how TMAs should respond to the wrongdoing of others. (shrink)

oise Baylis, 1234 Le Marchant Street, Halifax, Nova Scotia, Canada B3H 3P7. Tel.: (902)-494–2873; Fax: (902)-494-2924; Email: francoise.baylis{at}dal.ca ' + u + '@' + d + ' '//--> . Abstract Recently, there has been a growing interest in public health and public health ethics. Much of this interest has been tied to efforts to draw up national and international plans to deal with a global pandemic. It is common for these plans to state the importance of drawing upon a well-developed (...) ethics framework and we argue that this framework should reflect the values and insights of feminist relational theory. More specifically, we argue that pandemic planning must be squarely situated in the larger realm of public health and that an ethics framework for public health will be one that recognizes the need to pay particular attention to the vulnerability of subpopulations lacking in social and economic power. We propose an ethics framework for public health that builds on the notions of relational personhood (including relational autonomy and social justice) and relational solidarity. In this way, we aim for a public health ethics that, as appropriate, promotes the public interest and the common good. CiteULike Connotea Del.icio.us What's this? (shrink)

In recent years, feminist scholarship on emotional labor has proliferated. I identify a related but distinct form of care labor, hermeneutic labor. Hermeneutic labor is the burdensome activity of: understanding and coherently expressing one’s own feelings, desires, intentions, and movitations; discerning those of others; and inventing solutions for relational issues arising from interpersonal tensions. I argue that hermeneutic labor disproportionately falls on women’s shoulders in heteropatriachal societies, especially in intimate relationships between women and men. I also suggest that some of (...) the gendered burdens of emotional labor that feminist scholars point out would better be described as hermeneutic labor. Drawing on feminist philosophy as well as findings from social psychology and sociology, I argue that the exploitation of women’s hermeneutic labor is a pervasive element of what Sandra Bartky calls the ‘micropolitics’ of intimate relationships. The widespread expectation that women are relationship maintenance experts, as well as the prevalence of a gendered demand-withdraw pattern of communication, leads an exploitative situation to appear natural or even desirable, even as it leads to women’s dissatisfaction. This situation may be considered misogynistic in Kate Manne’s sense, where misogyny is a property of social environments rather than a worldview. (shrink)