Humanitarian Medicine and Ethics
Jerome Amir Singh
It has been argued that humanitarian medicine “goes beyond the usual therapeutic act and promotes, provides, teaches, supports, and delivers peoples’ health as a human right, in conformity with the ethics of Hippocratic teaching, the principles of the World Health Organization, the Charter of the United Nations, the Universal Declaration of Human Rights, the Red Cross Conventions, and other covenants and practices that ensure the most humane and best possible level of care, without any discrimination or consideration of material gain.” Given the complex nature of this field, humanitarian medicine practitioners should be cognizant of some of the ethical issues they could encounter in this line of work. This paper explores some of these issues and attempts to provide guidance in relation thereto. In particular, it will focus on the ethical issues implicit in introducing a new standard of care in a humanitarian setting, as well as the dual loyalty obligations implicit in practicing and conducting research in humanitarian settings.
Introducing a new Standard of Care in Humanitarian Settings
Humanitarian medicine is often practiced in settings where the prevailing public health system is nonexistent, rudimentary, dysfunctional because of poor state policies and/or inadequate resource allocation, facing collapse, or has already collapsed (for example, as a result of a major natural disaster or sustained armed conflict). In such instances, the very presence of humanitarian organizations such as the International Committee of the Red Cross (ICRC) or MSF may render them the primary providers of health care services by default. Humanitarian medicine practitioners entering such settings may find that the best existing standard of care for a particular health condition is absent in that setting. This state of affairs could give rise to an ethical dilemma: Should humanitarian medicine practitioners introduce a new standard of care into a humanitarian setting if the existing local standard of care for the health condition at hand is “no treatment,” if efficacious treatment exists elsewhere, and if it would not otherwise become available?
Not introducing the best existing standard of care in a setting that lacks it will mean that the health issue at hand will remain unaddressed, resulting in dire public health consequences for that setting, and, in some instances, the surrounding region. However, while introducing the relevant standard of care may, on the face of it, seem to be ethically obligatory, it may, in certain instances, yield more negative consequences overall. Humanitarian initiatives are often “parachute missions,” entailing only a temporary provision of humanitarian services until the humanitarian emergency in question has been stemmed and the setting stabilized. When such stabilization occurs, the humanitarian service provider typically withdraws from the region, and their relevant provision of humanitarian aid, including medical services, ceases. In such instances, the introduction of the best existing standard of care, while laudable, may be unsustainable post-withdrawal, and, accordingly, not be in the interest of public health. For example, if treatment for HIV or TB is nonexistent in a particular humanitarian setting, the introduction and subsequent cessation of treatment for such diseases because the humanitarian mission has ended could yield drug-resistant forms of those diseases, unless the country’s authorities can continue to provide such treatment. If they are unable to, the costs of second-line treatment options for emerging drug-resistant strains of those diseases could prove prohibitively expensive for the country in question. Humanitarian medicine practitioners should thus carefully consider the implications of introducing new standards of care in settings where they envisage only a temporary presence. They should prospectively liaise with government authorities on the introduction of such care, and, where possible, negotiate the sustained provision of that care (with authorities and other humanitarian bodies, if applicable), after they withdraw from that setting.
The ethical principle of beneficence requires practitioners to assume an advocacy role by making reasonable attempts to change the prevailing poor state of health conditions in settings where they practice, if possible or necessary. However, humanitarian medicine practitioners should bear in mind the logistical challenges of doing so. For example, they may have to obtain regulatory approval for the introduction of a new standard of care/prevention (if relevant regulatory mechanisms even exist or are functional in the setting at hand), source preferential pricing for that care/prevention and secure associated sponsorship, train local health personnel to provide continuity of care by administer the newly introduced standard of care/prevention after the humanitarian mission ends, develop local laboratory capacity for surveillance of the condition at hand (if applicable), and establish effective infection control measures in relation to the health threat in question. These measures are time-consuming and could factor against the initiation of a new standard of care in some settings. Accordingly, it is arguable whether humanitarian organizations should introduce an efficacious standard of care in a humanitarian setting for just the duration of their mission, unless they can secure an undertaking from local authorities that the latter will assume the responsibility of continuing that standard of care, once the humanitarian service provider withdraws from the country. Humanitarian medicine practitioners need to be cognizant that they do not have the power to compel authorities to approve or to implement an efficacious standard of care. However, this should not stop such practitioners from trying to do so. If they are unable to secure such undertakings from authorities (or other humanitarian service providers, if applicable), they may have to reconcile themselves to not initiating that new standard of care in the setting for the limited period they will operate there if doing so could have serious public health implications after they leave.
The Notion of a “Dual Loyalty” Obligation and Humanitarian Medicine
Health professionals, including clinicians and researchers, often have obligations to other parties besides their patients or research subjects—such as employers/sponsors and governments—that may conflict with undivided devotion to the patient or research participant. This competing interest can be characterized as a “dual loyalty.” In 2003 the Dual Loyalty Working Group (DLWG), a multinational, multidisciplinary team of experts versed in law, bioethics, and human rights proposed a comprehensive set of guidelines on dual loyalty conflicts, entitled Dual Loyalty and Human Rights in Professional Practice. Convened by Physicians for Human Rights and the Health Sciences Faculty of the University of Cape Town, the DLWG defines a dual loyalty as a clinical role conflict between professional duties to a patient and obligations, express or implied, real or perceived, to the interests of a third party. Humanitarian medicine practitioners could conceivably encounter a dual loyalty dilemma in the context of practice, or even in the context of research. Each context merits brief exploration.
Dual Loyalty Dilemmas in the Context of research in Humanitarian Settings
Humanitarian organizations sometimes find the need to conduct health systems research, operational research, or implementation research in settings where they operate. They may do this to better understand how they can improve their services, or to lobby apathetic or obstinate governments to change their existing treatment policies. In such instances, the conduct of research in humanitarian settings could give rise to challenging dual-loyalty dilemmas and conflicts of interest when the role of clinician and researcher combine. The toggling of clinician-researcher roles can create confusion for the research participant/patient as well as difficult conflict of interest dilemmas for the health professional concerned. For example, the physician’s primary duty to care for the patient and put his or her interest first could be undermined by secondary factors such as the duty to further the ends of science or protect the study sponsor/their employer (for example, if the research findings highlight improper or negligent practices on their part). There are differences in the ethical duties owed by a researcher and clinician. Research is usually conditional upon prospective third party review and approval while therapy typically isn’t. Similarly, the roles of research scientist and clinical practitioner are also very different. Morin, et al. describe the difference as follows: Investigators act to generate scientific knowledge that may potentially result in future therapeutic benefits. Practitioners are focused on present health and welfare of patients.
The distinction between research and treatment is particularly not clear to the patient-participant. Since subjects might misconceive the nature of a research project, particular attention must be paid when researchers offer some medical benefit that can be integrated easily into a course of treatment. Although trial patient-participants may be offered a treatment of unproven efficacy, some may believe they are receiving “cutting edge” treatment guaranteed to improve their condition. Moreover, they might believe that the purpose of a study or clinical trial is to benefit them rather than just gather data for the purposes of contributing to scientific knowledge. This phenomenon has been termed “therapeutic misconception.” Morin, et al. note that this perception may be reinforced when subjects receive the same experimental treatment from the same clinician who has administered medical care to them in the past, in contrast to being referred to a clinical investigator located in an academic setting with a reputation for conducting research. In such instances the US National Bioethics Advisory Commission has advised that researchers make clear to research participants, in the initial consent process and throughout the study, which activities are elements of research and which are elements of clinical care. They should also indicate in their research protocols how they would minimize the likelihood that potential participants may believe mistakenly that the purpose of the research is solely to administer treatment rather than to contribute to scientific knowledge.
Dual Loyalty Dilemmas in the Context of Practice in Humanitarian Settings
Humanitarian medicine practitioners may encounter irrational or unreasonable state policies (or even irrational or unreasonable internal policies of their own organization) in the course of their work. This could place them in a difficult ethical dilemma as, in the case of the state, exposing or attempting to stop such state practices could enrage local authorities and threaten the very presence of the humanitarian body in that setting. Conversely, failing to act or speak out against certain practices in the humanitarian setting could, in certain instances, have an impact on how the organization is perceived by local (or even international) stakeholders.
In its proposed General Guidelines for Health Professional Practice, the DLWG provides helpful guidance on how health professionals should handle dual loyalty obligations of the nature outlined above. The Guidelines are designed to address how the health professional can identify situations where subordination of patient interests to those of the state or other third party implicates human rights; clarify the responsibilities of the health professional in these situations; and enable the health professional to respond appropriately, especially where the health professional faces personal or professional risks by adhering to obligations to the patient.
According to the Guidelines, where the state has failed to take necessary steps to establish a health system that affords equitable access to health services, the health professional participating in that system has an obligation to press for alternative policies designed to change this state of affairs. Rather than adjust one’s behavior to the constraints imposed by discrimination or the state’s failure to develop a fair and equitable allocation of health resources, the health professional should act to change it.
Admittedly, such actions may not be possible or feasible in some humanitarian settings. In such instances, humanitarian organizations should prospectively plan how to manage such occurrences should they arise in the course of their humanitarian missions. Doing so could include prospectively establishing relevant stakeholder engagement mechanisms and communication strategies, if applicable.
The practice of humanitarian medicine can be a rewarding but daunting experience. Those involved in this field should carefully consider the ethical dimensions of their acts and omissions. They should also make a concerted effort to learn about the relevant instruments of international (and domestic, if applicable) human rights law, international humanitarian law, and refugee law, as these may be applicable to the settings that they operate in. Doing so will help humanitarian medicine practitioners resolve some of the complex ethical challenges they may encounter in the course of their work, which will ultimately benefit their patients.