Ethics in Disasters and Conflicts

Original Editors - Andrea Sturm

Top Contributors - Naomi O'Reilly, Kim Jackson, Tarina van der Stockt and Jess Bell      

Introduction[edit | edit source]

Natural disasters, armed conflict, migration, and epidemics today occur more frequently, causing more death, displacement of people and economic loss. Ethical problems that healthcare professionals are confronted with are different from those in everyday practice. To prevent the violation of basic Human Rights,[1] avoiding harm and finding the most beneficial action, an understanding of types and determinants of ethical situations is needed.[2]

A “disaster” clearly differs from an “emergency”, and has been described as a situation or an event that overwhelms local capacities and necessitates national or international external assistance. The increased needs of the population, damages of infrastructure and loss of healthcare professionals create an imbalance that hampers healthcare systems. Daily routines get lost and are replaced by stressors, such as massive workloads, scarce resources, threats to their lives or those of relatives and patients, a lack of legal guidance or regulation and health policies, as well as language barriers and culturally diverse backgrounds[2][3] – all of these factors can potentially contribute to moral distress. Experiencing moral distress can be associated with unresolved feelings of incompetence, compromised integrity, frustration, anger, powerlessness, outrage, and sadness.[4]

The demands of urgent and vital action can pose various value problems that may come along with decision-making about life and death, e.g. by triaging patients, or coping with issues related to relief. Such ethical issues can even persist into post-acute phases, lasting in some instances for years or decades.[2] For example, in Afghanistan, a great number of the Afghan people are suffering from disabilities, which are not only related to trauma and injury by war, but also to poorly or non-managed conditions, such as poliomyelitis and tuberculosis, because of the breakdown of health service infrastructure and resources.[7] Physiotherapists from Nepal reported a massive destruction of healthcare institutions and an overstretch of remaining healthcare facilities after the earthquake in 2015, and the continuous need for mid-and long term rehabilitation services of physically and psychologically injured survivors. Additional challenges arose due to the destruction of dwelling places and loss of housing, destruction of infrastructure for travelling safely to or from rural areas, and the arriving monsoon season causing floods. The monsoon season further increased the risk for diseases such as cholera and diarrhoea by affecting water safety.[8]

Ethical issues emerging in disasters have been identified as tensions between the respect for local customs and values imposed by external responders; different understandings of health, illness and diseases; external factors that hinder the provision of adequate care such as scarce resources; questions of a “moral identity” for health workers; and trust and distrust between humanitarian workforce and local communities. Professionals’ roles and interactions are influenced by historical, political, social and commercial structures, aid agency policies and agendas that can contribute to ethically challenging situations. For example, public authorities’ attitudes can create ethical dilemmas if they refuse to share information or do not authorise operations where it could become inconvenient, e.g. in refugee camps or war zones. Also the mass media’s mind-set and attitude after a disaster has been reported as creating ethical issues, when reporters block relief efforts in order to get closer images. Personhood rights may be violated when images of dead and wounded people get published, and could be seen by their relatives. Furthermore, the mass media may hide the truth intentionally and even spread misleading news under political pressure.

International relief organisations have been reported as approaching local organisations in a paternalistic and imperious manner. Some organisations were described as using relief activities for advancing their own agendas, such as religious motivations, political aims or raising funds. Unjust resource allocation and the ineffectiveness of humanitarian relief are other ethical issues arising in disaster settings. There are also problems related to sending, storing, and distributing relief. Politicians who abuse their power for the sake of their own agenda have been described as causing discrimination in distributing relief on the basis of religion, ethnicity and political views. Another significant ethical issue is mismanagement due to under-preparedness, such as a lack of rapid health assessment to determine actual needs. This may result in misallocation of resources, eventually leading to preventable suffering and death.[2]

Ethical issues can also arise on the level of the patient-healthcare professional relationship. Healthcare professionals may experience professional incompetence if they are not trained specifically for disasters or when triage is not applied properly or not applied at all. Healthcare professionals can have difficulties determining the limits of their duty to care, as discussed by ethicists in relation to the COVID-19 outbreak,[9] or in obtaining informed consent and respecting patients’ autonomy. Health professionals recommended for the sake of easing their workload that informed consent should not be defined as a professional duty in the first three to five day after the occurrence of a disaster (“initial chaotic phase”) because of very limited resources, and the psychological state of affected people. When a patient is a refugee who does not know the local language, obtaining informed consent may also be perceived as being too difficult. Violations of confidentiality and privacy are also ethical issues reported in disaster settings, as patient records cannot always be kept in lockers. This creates risk, especially for domestic violence victims and drug-addicts.[2]

Professional guidelines and regulations are not always providing sufficient guidance in disaster settings. Foreign organisations often have their own codes, which can conflict with local values and conditions. To understand local perspectives, healthcare professionals need opportunities to discuss, and access outside perspectives. They also require attitudes such as humility, open-mindedness, and reflexivity. Ethical practice in a humanitarian setting also requires healthcare professionals to consider the values and perceptions of national healthcare staff, to facilitate dialogue, and to increase trust and respect.[2] It is important to understand experiences and perceptions of local healthcare professionals who may have suffered physically, emotionally and/or psychologically from the effects of the specific disaster or the resulting privation. Healthcare professionals in disaster settings are not just contributing to the provision and rebuilding of healthcare, but can also be seen as a source of hope and moral direction.[7]

One example of a universal ethical guideline is the “Code of Conduct for the International Red Cross and Red Crescent Movement (ICRC) and Non-Governmental Organisations (NGOs) in Disaster Relief”. This guideline has the aim of maintaining high standards of independence and effectiveness. In the case of armed conflict, the code is interpreted and applied in conformity with international humanitarian law. The code, which is endorsed by World Physiotherapy,[10] includes ten guiding principles and three apexes that describe the working environments that ICRC needs from host governments, donor governments and intergovernmental organisations to provide effective humanitarian assistance[11]:

  1. "The humanitarian imperative comes first
  2. Aid is given regardless of the race, creed or nationality of the recipients and without adverse distinction of any kind. Aid priorities are calculated on the basis of need alone
  3. Aid will not be used to further a particular political or religious standpoint
  4. We shall endeavour not to act as instruments of government foreign policy
  5. We shall respect culture and custom
  6. We shall attempt to build disaster response on local capacities
  7. Ways shall be found to involve programme beneficiaries in the management of relief aid
  8. Relief aid must strive to reduce future vulnerabilities to disaster as well as meeting basic needs
  9. We hold ourselves accountable to both those we seek to assist and those from whom we accept resources
  10. In our information, publicity and advertising activities, we shall recognise disaster victims as dignified humans, not hopeless objects"[11]

Resources[edit | edit source]

The Ethical Principles of Health Care in Times of Armed Conflict and Other Emergencies, World Physiotherapy

References [edit | edit source]

  1. United Nations. Universal Declaration of Human Rights [Internet]. 2015 [Cited 2020 Jul 12]. Available from: https://www.un.org/en/universal-declaration-human-rights/
  2. 2.0 2.1 2.2 2.3 2.4 2.5 Civaner MM, Vatansever K, Pala K. Ethical problems in an era where disasters have become a part of daily life: A qualitative study of healthcare workers in Turkey. PLOS ONE. 2017 Mar 20;12(3):e0174162.
  3. Leider JP, DeBruin D, Reynolds N, Koch A, Seaberg J. Ethical Guidance for Disaster Response, Specifically Around Crisis Standards of Care: A Systematic Review. Am J Public Health. 2017 Sep;107(9):e1–9.
  4. Carpenter C. Moral distress in physical therapy practice. Physiother Theory Pract. 2010 Feb;26(2):69–78.
  5. PracticalBioethics. Disaster Ethics: An Introduction by Michael Weaver, MD. Available from: https://youtu.be/QmQOEnvpOEY[last accessed 09/03/22]
  6. PracticalBioethics. Disaster Ethics: The Collision between Public Health Ethics and Clinical Ethics. Available from: https://youtu.be/JYYAGJB5t4E[last accessed 09/03/22]
  7. 7.0 7.1 Edwards I, Wickford J, Adel AA, Thoren J. Living a moral professional life amidst uncertainty: Ethics for an Afghan physical therapy curriculum. Adv Physiother. 2011 Mar 1;13(1):26–33.
  8. Nepal Physiotherapy Association. The Role of Physical Therapists in the Medical Response Team Following a Natural Disaster: Our Experience in Nepal. J Orthop Sports Phys Ther. 2015;45(9):644–6.
  9. Schuklenk U. What healthcare professionals owe us: why their duty to treat during a pandemic is contingent on personal protective equipment (PPE). J Med Ethics. 2020 Jul 1;46(7):432–5.
  10. World Physiotherapy. The Ethical Principles of Health Care in Times of Armed Conflict and Other Emergencies - Endorsement. 2019. Available from https://world.physio/sites/default/files/2020-04/E-2019-HCiD.pdf [Accessed 22 March 2022]
  11. 11.0 11.1 Code of Conduct for the International Red Cross and Red Crescent Movement and Non-Governmental Organizations (NGOs) in Disaster Relief - ICRC [Internet]. 1; 00:00:00.0 [cited 2022 Mar 12]. Available from: https://www.icrc.org/en/doc/resources/documents/publication/p1067.htm