Evaluating underpinning, complexity and implications of ethical situations in humanitarian operations: qualitative study through the lens of career humanitarian workers.

INTRODUCTION: Data regarding underpinning and implications of ethical challenges faced by humanitarian workers and their organisations in humanitarian operations are limited.
METHODS: We conducted comprehensive, semistructured interviews with 44 experienced humanitarian aid workers, from the field to headquarters, to evaluate and describe ethical conditions in humanitarian situations.
RESULTS: 61% were female; average age was 41.8 years; 500 collective years of humanitarian experience (11.8 average) working with diverse major international non-governmental organisations. Important themes included; allocation schemes and integrity of the humanitarian industry, including resource allocation and fair access to and use of services; staff or organisational competencies and aid quality; humanitarian process and unintended consequences; corruption, diversion, complicity and competing interests, and intentions versus outcomes; professionalism and interpersonal and institutional responses; and exposure to extreme inequities and emotional and moral distress. Related concepts included broader industry context and allocations; decision-making, values, roles and sustainability; resource misuse at programme, government and international agency levels; aid effectiveness and utility versus futility, and negative consequences. Multiple contributing, confounding and contradictory factors were identified, including context complexity and multiple decision-making levels; limited input from beneficiaries of aid; different or competing social constructs, values or sociocultural differences; and shortcomings, impracticality, or competing philosophical theories or ethical frameworks.
CONCLUSIONS: Ethical situations are overarching and often present themselves outside the exclusive scope of moral reasoning, philosophical views, professional codes, ethical or legal frameworks, humanitarian principles or social constructivism. This study helped identify a common instinct to uphold fairness and justice as an underlying drive to maintain humanity through proximity, solidarity, transparency and accountability. © Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Humanitarian situations compel ample amounts of ethical challenges to aid workers and their respective organisations, but limited empirical data exist to guide the industry in addressing them.

In-depth discussions with career humanitarian workers helped discover important overarching themes, with multiple contributing and/or contradictory factors, and evaluate shortcomings, impracticality, or competing of available philosophical theories, professional codes, ethical or legal frameworks, or humanitarian principles.

We identified a primary desire to rectify most unjust situations and uphold fairness and justice as an underlying drive to maintain humanity through proximity, solidarity, transparency and accountability, which could shed light onto the industry’s strengths and shortcomings and guide its practices.

Career humanitarian workers are not representative of the entirety of aid workers, and there is no information about the beneficiaries’ ethical experiences or views.

Inroduction

Globally, humanitarian situations continue to be prevalent since their current-day recognition in the second half of the 20th century.1 Within the past decades, there has been an increasing number of individuals and organisations responding to humanitarian situations or crises, including more than half a million national and international staff, with millions involved in some form of humanitarian efforts.2 3 Humanitarian situations, by their nature, are chaotic and dysfunctional, frequently depleted of social, healthcare, and structural support systems from the beginning, often becoming protracted with continuing morbidity and mortality.4 Despite efforts to organise, coordinate and streamline humanitarian efforts, especially healthcare services, the humanitarian community remains heterogeneous, with multiple ideological frameworks and significant variability in degree of training and technical expertise.1 5 6 Additionally, international and local stakeholders, employees and volunteers may have divergent or conflicting perspectives on their roles and responsibilities to host communities.7 At the same time, trends in volunteerism have resulted in influxes of semiprofessional humanitarian corps, sponsored largely by philanthropists, academic and religious institutions, which participate in short-term or non-systematic engagements.8 9

This unique constellation of barriers in such a diverse, sometimes disjointed, community has resulted in difficulties navigating the humanitarian field and has given rise to an ample amount of ethical challenges.9–13 Additionally, this has led to high rates of turnover and burnout among humanitarian workers and has put a strain on a humanitarian system seeking to retain professional aid workers and maintain quality and sustainable initiatives.2 14 15 Research has identified psychosocial factors and different emotions in volunteerism,16 and some data exist describing the moral experience from exposure to humanitarian situations.2 11 12 Through a qualitative approach, we evaluated ethical situations and their impacts on and implications for humanitarian operations and the workforce.

Methods

We recruited 44 participants using prospective purposive, snowball and criteria sampling techniques. Initial contacts with major international non-governmental organisations (INGOs) and discussions with key humanitarian field informants helped identify initial participants. We included different genders, ages, family status, educational backgrounds, geographical locations and types of humanitarian work to the extent possible. Inclusion criteria included (1) aid workers from any major humanitarian INGO outside their country of origin, (2) minimum of 3 years of direct international experience and (3) supervisory and/or coordination experience at country or headquarter levels. Exclusion criteria included individuals who exclusively worked for governmental, United Nations (UN) or local aid agencies. We, however, included all aid workers who worked for any of the aforementioned entities plus non-governmental and international humanitarian agencies as national or international staff. This distinction was made largely because governmental, UN and/or local disaster agencies may have different mandates, missions and visions, dependency, and accountability processes, and often lack volunteerism features or mandates for humanitarian principles which could impact the perceptions and experiences of ethical challenges.

Overall, we contacted 60 participants and concluded recruitment with thematic saturation with 44 participants from 2010 to 2012. Most of participants were working overseas and not available in person to provide written consent; therefore, verbal consent was obtained. This study was part of a larger study that included 16 open-ended questions in humanitarian experiences.13 Ethical questions and probes elicited moral and ethical experiences and emotional stressors. We incorporated responses from all questions that were relevant to the research question.13 Using complementary data gathering methods, we conducted semistructured interviews, along with analyses of aid industry discourse relevant to the ethical and moral themes. Originally, we conducted informal interviews with key players and informants as individuals possessing knowledge relevant to the research question, including those with background in aid operations and ethical, moral and philosophical ideologies to improve validity and accuracy. Interviews were audio-recorded and transcribed. Following the theoretical framework and conceptual model guiding the study,13 two coders coded transcripts through open, inductive and selective coding. They discussed discrepancies to improve reliability, analysed data, characterised and agreed on important emerging themes, and compared themes across cases to elucidate commonality and variability. Observational data and non-verbal communication (intonation, pauses and voice reactions) were also evaluated to enhance analysis. We used a qualitative descriptive approach to analyse data. The lead author has decades of experience in humanitarian operations working with major humanitarian organisations, as well as academic and research experience in the fields of accountability and ethics in the humanitarian sector. Although this background could potentially introduce biases into data analysis, it has largely improved its depth and rigour by better developing questions and probes, identifying and exploring views from key informants, and addressing the inter-relationship between the ethics and accountability.

Patient and public involvement statement

At early stage of the study, formal and informal discussions with practitioners and key informants from the humanitarian field were held to better develop the research question and understand the potential impact of research, and factor in their current experience and priorities to the extent they were relevant. Results and final analysis will be provided to participants through peer-reviewed publication.

Results

Table 1 presents participants’ sociodemographics. Box 1 presents participants’ positions, locations of humanitarian work and respective organisations. Participants’ assignments included emergency, longer-term medical and public health, or development projects. Their interview-time positions included field supervisory but primarily headquarters-based.

Table 1

Demographics and characteristics of career humanitarians

Characteristics (N=44)	n (%)
Gender
Male	17 (39)
Female	27 (61)
Age group (years)
<30	1 (2)
30–39	18 (41)
40–49	19 (43)
>50	6 (14)
Average age	41.8
Region of origin
Africa	1 (2.25)
Asia/Oceania	3 (6.75)
North America	21 (48)
Europe	19 (43)
Educational/professional background*
Medical	14 (32)
Public health	11 (25)
Allied health (i.e., nursing and occupation therapy)	6 (13)
Political science	7 (16)
Law	1 (2)
Social sciences (sociology and anthropology)	4 (9)
Earth/biological sciences	3 (7)
Finance	3 (7)
Number of years in humanitarian field
3–5	5 (11)
6–10	15 (34)
11–15	10 (23)
>15	14 (32)
Number of missions (means primarily working in the field not field trips)
3–4	11 (25)
5–6	9 (20)
7–8	9 (20)
9–10	6 (14)
>10	9 (20)
Range of duration of mission	1 month–2 years
Average number of missions	7
3–5	15 (34)
6–9	19 (43)
10+	10 (23)
Area of humanitarian experience*
Africa
Northern	22
Western	18
Eastern	20
Southern	1
Middle	22
Asia	29
Americas	20
Europe	11
Current position
HQ	17 (39)
Field	10 (23)
Both†	12 (27)
In between position	5 (11)
Current humanitarian agency‡
International NGO	37 (84)
UN agencies	5 (11)
International governmental organisation	2 (4.5)

*These are not exclusive categories.

†Participants who indicated they did both HQ/coordination-level work and field work; this was described as mostly HQ work, with shorter missions into the field.

‡Participants who indicated working in UN or IGOs had previous experience with INGOs.

HQ, headquarter; IGO, international governmental organisation; INGO, international non-governmental organisation; UN, United Nations.

Areas of international humanitarian experience

Afghanistan, Angola, Bahrain, Bangladesh, Belize, Bosnia, Burkina Faso, Burundi, Cameroon, Central African republic, Chad, Chechnya, China, Christmas Island, Columbia, Congo, DRC, Dominican Republic, East Timor, Ecuador, Egypt, El Salvador, Ethiopia, Georgia, Ghana, Guatemala, Guiana, Haiti, Honduras, India, Indonesia, Iraq, Ivory Coast, Jordan, Kenya, Kosovo, Kyrgyzstan, Liberia, Libya, Macedonia, Madagascar, Malawi, Mali, Morocco, Mozambique, Myanmar, Nicaragua, Niger, Nigeria, North Korea, Pakistan, Palestine, Rwanda, Russia, Senegal, Sierra Leone, Sri Lanka, Somalia, Somaliland, South Africa, Sudan, South Sudan, Tanzania, Thailand, Turkmenistan, Uganda, Ukraine, Uzbekistan, Vietnam, Yemen, Zambia, and Zimbabwe

Type of current position

Chief executive officer, chief/senior health advisor, chief medical officer, chief of health department, country director, director of emergency preparedness and response, director of human rights country office, director of human resources, director of humanitarian affairs, director of humanitarian studies, director of operations, executive director, executive medical coordinator, field physician, finance manager, head of mission (country level), health/medical coordinator, humanitarian policy advisor, infectious disease surveillance coordinator, logistical coordinator, member of board of directors, programme coordinator/manager, programme officer, president of organisation (former and current), resident advisor for malaria, senior advisor for social development, senior health consultant, senior health director, technical advisor for women's empowerment, technical health advisor, WHO oordinator

Organisations

Médecins Sans Frontieres, International Federation of Red Cross and Red Crescent, ICRC, International Rescue Committee, Save the Children, Action Against Hunger, the MENTOR Initiative, Human Rights Watch, Doctors for Global Health, WHO, UNICEF and United Nations High Commissioner for Refugees

Several major specific and inter-related themes were identified, each with distinct overarching subcategories lumped under one umbrella, at times arbitrarily, to preserve the logical flow. Table 2 presents related quotes.

Table 2

Quotes regarding ethical experience of career humanitarian workers

Themes	Quotes
Resource allocation schemes and fair access to and use of services
Programme-level resource scarcity	‘You’re working on a big project and you’re working in a camp setting, and every single individual in that camp has individual needs and things they need (to be) addressed…on a problematic level, you are, for simplification sake, let’s say you give everyone two goats and one jerry can …, and these emergency supplies and rations, and so you lose, a little bit, the individual worry’ [13]’The staff, which is probably a major, they become really attached to a specific kid with a specific problem, go to extraordinary lengths to get them to a place where they have some advanced procedure, heart surgery or whatever, um that allows them to survive. and when they do, it’s a wonderful thing, but how much that help should be allowed, how much that staff should be spending… a lot of time and energy on an activity like that, vs, you know, with the potential that it takes them away, even if only for the week or two that they’re planning this whole thing, form their normal duties, and their concentration on all the kids that we could be helping more’ [25]‘And so on a few occasions, I was privy to okay this girl grabbed me by the hand and is begging me to come to this tent and I see her father whose leg was broken in the earthquake about eight months before and it’s still in one of these metal casts with the pins going into his leg, its oozing, its badly infected, the worst stories, tell me the worst story that you can imagine, and again, then you can’t not do anything. So but then also, everyone, then that neighbor, the neighbor has a story like that, and then the cousin has a story like that’ [13]
Broader aid context and allocations	‘There have been plenty of times where I’ve had to turn patients away from care, not because we didn’t have the ability to help them but because they weren’t our target population. In those circumstances, sometimes I ignored the rules and treated them and sometimes I directed them to the next best thing. But as I continued doing the work longer and longer, you realize why the rules are in place so it becomes easier to make the decision, but of course it doesn’t feel good when you still try to do the best you can within the rules’ [14]
Organisational and individual competency and quality of aid services
	‘Well I think just in general you know the NGO community and how much we either work together or are at odds with each other … How much we tried to coordinate care and sort of provide and work with the government at local levels opposed to you know random academic center that had never been overseas and had never worked in HIV care and in Africa is going to go and set up shop and you know provide high level care that you would find in the United States for just a hundred people. Uh, meanwhile you know there are thousands who need moderate care and attention can’t get it. I think that’s the tricky uh tricky question that you need to reflect upon’ [9]‘Not having the right combination of medications available, especially for pain control. In aid orgs like mine, we don’t have a comprehensive approach to pain. Post-op pain, pain from injuries. Pain from infection. I think things need to be done about that’ [32]
Process, impact and effectiveness of aid efforts (utility vs futility), and unintended consequences
Negative consequences of aid	‘Um, well yes. I worked in one program, one mission on the field where, basically…um, where the (government’s) power had thrown the other one out, so basically it was a coup d’état. And the government in power was regrouping populations to try and cleanse the hills of rebels. So they were taking all these rural, you know, farmers, and regrouping them into camps, so that they could… control the hillsides, and…you know, they knew who was where and whatever. And so they regrouped people in about ten camps, we’re talking like one hundred thousand people. And they did not…offer them any food…any healthcare. They weren’t allowed to go back to the field to tend their crops, and any of that. So obviously a very bad situation. And we went to work there, meaning we were providing healthcare, we were doing nutritional feeding programs and so on. And I think we were thinking what were we doing, were we being the logistic arm of this government…, what was the point of this? Were they just using us, were we just going in, doing our thing, because it needed to be done, without really thinking well, what are we really doing here?’ [28] ‘We had this project on HIV…the focus was to have the population tested… And we had a group of prostitutes who were attending or visiting every now and then on a regular basis, and we were providing them condoms and free gynecological care if they were willing to…So we were telling those girls to get tested, get tested, all the time. So at the end, they got tested…and one of them was positive. So this girl just disappeared, and the dilemma was of course afterwards…She just disappeared. And the other girls who were with her, they had realized that she was positive, because in the post-testing session, well she looked a bit different than the others, she was a bit more shaky…So the dilemma was like, what do we do now? And there was no way to get back to this girl, she had just run…Was it correct to push so much to test? Maybe we shouldn’t have done it, you know? And the dilemma is, have we done something correct to these girls? Maybe not. And it’s not a dilemma,…it’s an afterthought, or I don’t know how you want to call it. You know, this is one of the things that I think sometimes, like, wow. She was like nineteen or something. Hmm’ [20]
Effectiveness, decision-making process, values and roles, sustainability	‘During the tsunami, the organization faced ethical dilemma…in the first days following the tsunami, we received a very large amount of money,…and we had teams on the ground already, and in places we were already operational, like Sri Lanka. But we sent teams in Indonesia, and Thailand, and, um, actually we realized that there were a lot of actors on the ground, we realized that there was no immediate physical need. We realized that the country that had been affected had actually the means to respond. And they were even more qualified and better equipped than we were to respond to this. So the ethical dilemma was what do we do, because if we keep taking the money, the donors they sent it to us to spend it for this crisis, but we don’t see any value for (my organization) to be participants in this. On the other hand, if we don't keep it, it would look very bad in the NGO community, because some of them they need this money, and we would send a signal, a message to the public opinion that there’s no need for money. So it was a dilemma’ [30]‘As a relief organization, we focus very much on the short term, although sometimes, post conflict, we are also involved in capacity building. But that requires an investment very much in, you know, saving lives now vs saving lives in the future. And that more has to do with programming, you know, how you set up your programs, what’s your focus. But that is more in development, you know, transitional development’ [27]
Corruption, diversion, complicity, competing interests, aid hidden agenda and intentions versus outcomes
Programme and country-level corruption	‘During a seed distribution in Kosovo, the village heads came in the middle of it, pretending [so they could] be served first. I tried my best to avoid this behavior coming under my responsibility but they threatened [to stop] the full distribution project. I knew they could block it, so after making clear my thoughts about it, I gave up and served them because I didn’t feel secure myself’ [1] ‘We have all experienced…when you are asked for bribes…at a check point. This is not even a dilemma, because we have a policy as an organization to say no. But it’s difficult to negotiate, and it’s tempting sometimes to, um, think that it will solve immediately the problem, and maybe we are putting ourselves in danger by refusing’ [30]
Government and international agency corruption	‘When it comes to the UN, I mean the first thing I have issues with are the high salaries that we pay people, me included. Because you really have to wonder, like, is what you are getting paid, um, according to the output of the person. And I know that, like, that’s a really hard thing to kind of assess, because you can see, like, CEOs on Wall Street making, you know, like millions in bonuses. How much are they really putting in? So that’s like a question there. But I feel like, when it comes to the UN or humanitarian agencies, it’s like, you are, the definition of humanitarian, you are doing it to help others. Right? So in a way, you taking a huge bonus, is, to me, an ethical issue’ [26]
Complicity and aid’s intention versus outcome	‘You wonder if sometimes your projects are perpetuating a laziness… of governments that you’re working in. Um, and you sort of start to wonder if you’re like uh what your role is in that and if you’re complicit in the perpetuation of a corrupt system’ [5]’There was a war between a group called the Sinhalese and another group called the Tamils. And the Tamil’s lost the war, and at the end of the war the Tamil’s were sort of collectively imprisoned in a camp, which was in the northern part of the country. It was a pretty grim place that was primarily run by the military. [my organization] had a hospital that was on the fringes of the camp, this sort of detention camp, and there was an ethical question as to whether we were somehow facilitating or enabling the Sinhalese who had won the war to maintain this inhumane and bad camp by being there. There was an ethical dilemma as to what should have been our role in that scenario’ [21]‘Is it the role of NGOs to replace what the government should be doing?…. That’s kind of larger ethical problem, the usefulness of it. Are we there because we’re useful or are we there just because it’s the market and NGOs are in it just for the market and once you’re in there you need money and you need to find funders and donors and therefore you just need to find problems to get the money and pay your employees kind of’ [4]
Professionalism, behaviours, and interpersonal and institutional responses
	‘We had a report of violence; a peacekeeper had perpetrated against a community member. I didn’t know how to deal with it, so I reported it to my supervisor, and he didn’t really know what to do, and that case might have been lost if I hadn’t pushed…advocating that there was follow-up’ [42]‘the other thing is like, life [could] get really comfortable when you are living in that comfortable ex-part environment, where…you have diplomatic status…your own car, a nice apartment… money. So, you are…you re no longer in the emergency phase’ [26]
Exposure to extreme inequities, emotional stressors and moral distress
	‘The most difficult times were those days where you would either hear [or] bear witness to this horrific story and… there was nothing that you could do to help make it better’ [6]’I mean, just, this is kind of general but just being a humanitarian worker in a place where everybody is suffering. It’s an ethical issue’ [17]

Resource allocation schemes and fair access to and use of services

Programme-level resource scarcity

Most concerns were related to general scarcity of resources, especially pervasive when confronted with medical or social needs that were not necessarily unique to humanitarian crises, but rather limited support systems and infrastructure. Participants struggled with how best to allocate resources to communities, individuals or populations with the greatest medical needs versus those who were relatively stable. They acknowledged that, in a resource-limited setting, meeting the needs of one constituency would likely mean taking away resources from others. Therefore, they felt their morality was confronted in their decisions to focus on one problem versus another or the extent to which they should allocate resources (ie, women vs men vs children vs other vulnerable groups or specific diseases or location within those communities).

Another one that comes up really often is…kids who may have a measles and you may not be able to treat, 95% of all the kids effectively for their complications, but then there are going to be kids with heart disease with renal failure, or whatever. They could be treated at a referral hospital somewhere, if, if one could get there and obviously, it’s sort of a bottomless pit’. [25]

Broader aid context and resource allocations

Participants also reflected on difficulty coping with broader decision-making processes in the aid system or within their own organisations regarding resource allocation.

I’ve had programs where you have, whatever, 500 families, let’s say 2500–3000 people, in a district that had 350 000 people, so how’s that? What do you do if an INGO, [INGO name] is large enough so that some of the projects can be large, but they’re still not as large as what a government can do and should be doing [4]

They identified the issue of lack of transparency and communication regarding continuous decision-making by different stakeholders and within different levels of administration. This created unclarity regarding what conditions, programmes, population groups, communities or countries to invest in or focus on.

Organisational and individual competency and quality of aid services

Participants often struggled working outside of their competence. This was, however, seen largely on an institutional scale, with organisations forced to work beyond their capacity or competence to fill a vacuum due to pre-existing structural or organisational challenges or lack of meaningful alternatives.

Um, I mean, for example, we had a burn unit in a trauma hospital in Port Harcourt that I decided to close, um, just because I felt like we weren’t, we weren’t that good at it. Um, the patients, you know, occupied the beds for so long, and then often had complications, …then there were also the plans for that we each felt that what the university hospital,… that if we weren’t doing burns that it would be more likely that would move forward [25]

The unique situation of complex crises, as well as the resultant demands on healthcare workers and other staff, often meant deviations from standards of practice. Participants struggled with the ethical response to such variations in practice. Several participants elaborated on perceived low-quality medical care, often comparing to standard of care of their usual medical or public health practices.

Process, impact and effectiveness of aid efforts (utility vs futility), and unintended consequences

Participants were generally satisfied with their professional work. However, they were concerned with the real impact of their interventions on the health or overall well-being of beneficiaries both in the immediate context—for local target populations—and in the long term. They voiced ambivalence, frustration and disappointment in many of their experiences, derived largely from concerns about the effectiveness or utility and/or futility of their efforts in the face of overwhelming tragedies. Participants worried that aid systems do not truly address the fundamental causes of humanitarian situations and function at best as band-aid solutions with unclear sustainability or deeper impact on root causes that will mostly produce short-term fragile achievements. Participants also expressed concerns about poorly organised and unsuccessful programmes, leaving a programme prematurely or starting/implementing programmes without consideration for long-term or additional support.

The very general ethical question is to ask yourself whether what you’re doing is actually useful or not. Obviously, we all think it is in one way or another otherwise we wouldn’t be doing it. But I think it’s because you’re faced with…real horrors, or you can be faced with hunger or starvation, or you can be faced with illness or things like. [And] you really really want to do something about (it) and you feel guilty by telling yourself it’s useless, let me pull away… That’s one of the reasons you stay, I think maybe partly a little bit of guilt. I can’t help myself from asking, is it useful in the long run [4]

Negative unintended consequences of aid

Participants were particularly worried that their organisations’ work enabled corrupt governments or was co-opted or complicit for political purposes. Some worried that their participation created significant new problems for local populations (see table 2 for quotes).

Effectiveness, decision-making process, values and roles, and sustainability

Reflections on programmatic decisions highlighted discrepancies between personal and institutional priorities and values. Participants voiced discomfort with aid decisions they viewed as without the input from ‘the field’, and the disagreements between field workers and central administrators. They emphasised a lack of autonomy in decision-making for programming or broader interventions from actual field staff who deal with active scenarios. Others expressed concerns about the limited, redundant or incomplete roles of aid organisations versus other stakeholders in establishing well-run, comprehensive, and effective health projects or campaigns. Participants struggled with feelings of futility, disutility, lack of personal agency, or a disjunct between personal ethics and broader high-level decision-making entities in aid. Others had concerns about short-term sustainability of their programmes and/or their overall utility in view of scarce resources and their ultimate effectiveness, cost-wise or not. Others understood the necessity of being pragmatic with issues at hand and accepted that the sustainability goals are hardly achievable in the wider context.

We keep pushing, you now, the boundaries more, and we like, you know, to be innovative, but there, you walk the line all the time, is this cost-effective, is this applicable, is it, you know, is it maintainable [laughs] is it sustainable etc. [25]

Corruption, diversion, complicity, competing interests, aid hidden agenda and intentions versus outcomes

Programme and country-level corruption

Examples of small-volume diversion included navigating bribes and cash ‘gifts’ for members of host communities or liaisons. They frequently cited concerns of corruption, graft and fund diversion among local stakeholders and national staff.

We worked a lot with money, cash grants, cash transfers, and things or items that people really really want. It becomes really difficult for the local people who are your staff to deal with either their family members, or clan members, or tribe members and be fair and not being accused by them of being unfair…[or] the local community and chiefs or other elders might divert everything that you want to give to their extended family or to their extended clan or something like that [4]

Many participants viewed these as part of local customs, established exchange systems or necessary supplemental income for local staff that were accepted and helped navigate or maintain critical programmes. Corruption and resource diversion were seen to negatively impact effectiveness and morale of local staff, who were often seen as unfortunate middlemen in difficult situations involving familial, community and professional loyalties.

In the [country name], you cannot give money to anyone and expect them to distribute it, even when they know that they’ll be controlled, even when their own employees are people they have worked with for years. Um you know, it still seems to be impossible to assume that someone will just, you know, play, play ball with their own colleagues. You know, I think it’s a massive issue and one that we have in many places that we work [7]

Participants were often unsure how to confront these without jeopardising their programmes, personal relationships with community members or safety. Despite organisations’ policies regarding bribes and unsanctioned uses of resources, participants seldom had sufficient institutional or local support to successfully navigate these dilemmas.

Governments and international agencies’ corruption

Corruption was also seen on systematic levels. Participants expressed discomfort about perpetuating corruption at state, regional and national levels by enabling bad actors, or government or large-scale resource diversion away from vulnerable populations.

I mean, I think that [country’s name] is a particularly tricky country because they have a ton of funding from US government because they have oil and sometimes with that can go a lot pressure from your donors, who are mostly US based donor agencies so you sort of keep quiet like you know we need to make sure that the money goes into [country’s name] for malaria so you know if you think the rates aren’t as high as we think they are then you know you should have just kept your mouth shut [5]

Complicity and aid intentions versus outcomes

This included the impact of large influxes of donor financing, equipment, or other goods into countries with unstable or autocratic regimes, as well as in countries where economic or political relationships with donor countries impacted aid decisions. Participants frequently criticised practices by international parties such as donor-driven aid, foreign policy impact and relatively high salaries within UN or government-supported agencies.

Some ethical situations are, one example is donor driven funding. Where you have, you know, you have a donor who wants to give the money specifically to one area but each organisation has very specific needs. For example, we develop where we see a need, not developing that so we can find money. So, the way that that has been resolved is by, you know, communicating with donors. So we bring them around and allow us to change what they have determined to be the need but it’s just not possible sometimes and you actually have to just give back the money [15]

Others expressed trouble dealing with underlying intents of aid agencies and whether responses were truly based on altruism or simply business or industry. An important ethical dilemma arose when organisations had to choose between access to populations or speaking out about unethical practices by local entities or others.

Yes, I think that programmatically the example of the prisons in Rwanda and what we saw was so unacceptable, but at the same time it was a big decision because we knew by talking about the situation we knew that we probably would get expelled and we knew that the prisoners would probably lose it all together. So, I remember those discussions were very very difficult, and what we knew in the end is that [my organization] chose not to talk about it and we continued working there. I think that was looking back at it, I’m not sure whether that was the right decision [19]

Professionalism, behaviours and interpersonal and institutional responses

Improper behaviour by national or international staff towards host communities was a source of distress for aid workers who witnessed or suspected conducts that breached local customs, community values or local (or international) laws. Some additional concerns included substance abuse and improper sexual relationships. These were all seen as not living up to humanitarian standards or values.

You have these very personal ethical issues, like having staff going out with way too young children, young girls…You try to have a discussion about how that is just unethical, and especially [as] humanitarians, [but] that is not an easy discussion. [19]

Most participants were aware of their position of power and expressed additional discomfort at what they perceived as an exploitation of privilege by international workers. Many participants expressed uncertainty with confronting and/or reporting such behaviours and felt there was a lack of structure to address breaches in professional codes and conduct, which negatively impacted their agency’s services.

Emergencies that were happening around, and I would see my supervisors just kind of taking a relaxed attitude toward it because, one, they had been doing this for ten years, so nothing kind of surprises them, and they didn’t really spring into action, to some degree because they thought, like, oh I’ve seen it worse, or I know more than anybody else…I know how it’s going to play out [26]

Exposure to extreme inequities, emotional stressors and moral distress

Participants reported significant exposures to the extremes of crises: disease, starvation and other daily privations in humanitarian work. Personal narratives of experiences with inequity, widespread unjust distribution of resources, were powerful sources of emotion and caused feelings of distress, hopelessness or futility.

I’m wondering of how we can ethically leave this situation um leave the sort of context, leave the people there with enough to survive and start making it on their own [5]

Many participants reported feelings of isolation, loneliness, burnout, depression, and alienation regarding their mental and emotional management of these experiences; others used these experiences to express motivations for their humanitarian work. While many cited friends and family as important support, they also noted difficulties in sharing their experiences with people outside the tight humanitarian worker community. Few participants felt that their institutions provided sufficient services—in predeparture training, in-field debriefing or postdeployment support—to help them manage their experiences. Several others questioned the usefulness of such services.

Discussion

Aid workers, with over 500 years of collective humanitarian experience, reflected on ethical situations in humanitarian settings as opposed to healthcare at large. We did not investigate the specifics of any particular ethical challenges; instead, we explored them more broadly to elucidate meanings, undertones, inter-relationships and trends. The diversity, complexity and cross-disciplinary nature of these ethical situations make it difficult to describe or address them using common moral theories, philosophical views and ethical frameworks, as these often fail to be consistently applicable and may compete with each other or operate in parallel but contradictory ways.

Resource allocation has a clear impact on direct care provision and leads to ethical concerns for healthcare workers.17 18 The bioethics principles and clinical justice concepts that delineate basic principles such as urgency, need, avoiding worst outcomes, likelihood of benefit, efficacy, equality and non-judgemental care could help address triaging when resources are limited. Under usual circumstances, they will help providers to avoid distributing resources based on perceived individual merit, contribution to society, personal preferences or various personal gains.19 20 Nevertheless, these values are difficult to uphold in settings where collective decision making for the community’s welfare allows for redistribution of resources based on individual contributions to that society, and when norms, preferences and social constructs could differ from those of international providers (ie, value placed on elders’ vs children’s lives).

Beyond the patient level, however, rationing is pervasive and not peripheral.17 18 Allocation decisions both at micro and macro levels feature important elements such as characterising the best outcome and fair chances, a priority scheme, explanation of aggregation benefit and a democratic process to define fair rationing outcomes.21 Clearly, the chosen theories of justice matter, along with the incorporation of diverse beliefs and preferences in implementation, and the practical and moral magnitude of the composite utility. Hence, it appears any methodical rationing criteria will still be unable to encompass the values of all stakeholders. Others have suggested that rationing is not a moral issue but a practical social choice on morally sensitive matters.22 Given the humanitarian context, the likelihood that a rationing system could satisfy beneficiaries and staff alike is low. Compromise is then essential among competing moral visions.22 When doing the most good contradicts being fair or non-discriminatory, scholars have suggested to rank the condition-treatment pair as opposed to treatments for actual individuals and forego some fairness for the sake of promoting another good.23 In humanitarian situations, clearly not everyone can be treated.

Others argue that improved healthcare should not necessarily mean spending more resources, and discuss denaturalising scarcity because some settings are pervasively and consistently resource-limited and advocate searching for the root causes of illness and injury.24 Accordingly, in withholding services, others argue that futility results from scarcity of resources as a by-product of societal choice rather than patient’s condition. They discuss the legitimacy of such decisions,25 and the process of setting limits as opposed to the actual limits.26 Moreover, factors beyond the scope of providers’ control—such as appropriateness of basic resources, clinical or public health competencies, and the broader impact of higher-level decision makers on overall health services—complicate practitioners’ approaches within their own disciplines. Therefore, larger ethical challenges also arise from disagreements regarding operational priorities. While humanitarian organisations have mandates for setting operational limits and ensuring wide-ranging crisis response capacities, these are self-imposed and should be reconsidered if they cease to incite effective humanitarian responses.27 To address all this, constant critical self-reflection, deliberation with inclusion of perspectives from all stakeholders, greater specificity in ethical guidance, and a stronger evidence base for coaching international workers have been recommended.26 28–31

Competencies and quality of programming are theoretically possible to address using existing guidelines but appear futile considering overarching issues of complicity, hidden agendas, corruption, resource diversion or unintended consequences at programme, national, or international levels beyond aid workers’ scope or capacity. There is recognition of a paradoxical phenomenon that engaging in humanitarian work appears to contribute to worsening humanitarian situations, or that humanitarian work is unable to resolve inherently immoral or unethical situations. The issue of corruption was often seen as a structural symptom of larger systems of oppression and violence that compel individuals to act unethically. Furthermore, there are negative consequences of aid,26 politicisation and militarisation of aid, inequities and suffering of beneficiaries through furthering adverse political regimes or pervasive social groups,32 aid as a weapon of war and related power dynamics,26 security issues, complicity (ranging from conspiracy to negligence, consorting and contiguity), dysfunctions in aid systems, and broader structural injustice that all seem to operate beyond the control of many on-the-ground actors experiencing them.26 33–35

Many of our participants pointed out widespread accountability gaps as sources of ethical concerns.27 36 37 Scholars have criticised the humanitarian system in its underlying failures, gaps, and shortcomings in ideologies and theories; debated important concepts of paternalism, altruism versus self-interest, neocolonialism and features such as care and control, domination and emancipation, and intention versus outcomes; and discussed profound power dynamics and asymmetry between actors in the contemporary global governance landscape with conflicting interests that has shaped the social and political determination of aid.38 Organisations and staff also play important roles in this morally charged landscape through their legitimacy and underlying values,39 considering that humanitarian values and principles are largely from their social constructs and upbringing, societal morale, ethical expectations, concepts of rights or legal frameworks, and cultural relativism.

Aid workers’ behaviours, local norms and customs, and cultural appropriateness impact local populations and the humanitarian image, and have implications for duty of care for organisations.26 Similarly, there is specific attention to sexual abuse and exploitation.40 41 Clearly, the broader industry and contexts in which aid is funded, exercised, directed and governed have a significant impact on a wide range of such issues.37 Meanwhile, the residue of exposure to multiple humanitarian situations results in moral distress with its nuances of moral uncertainty, light moral distress, delayed distress, moral dilemma, bad moral luck, and distress by association when workers cannot preserve all interests at stake.12 42 43 Thus, this intolerability of injustice develops when aid workers grapple with the failure of morality when no normative theory could effectively direct to good outcomes or living with consequences of morally questionable actions.44 Accordingly, in humanitarian settings, there will be situations when moral reasoning and ethical frameworks fail to provide comfort to the decision makers, as well as those on the receiving end, even if they provide reasoning for acceptability and reasonableness of choices.

We should not overlook the historical perspectives, evolution, successes and shortcomings of philosophical value systems that address resource allocation, including priority allocation scheme that values the worst-off, egalitarianism and utilitarianism or collective gain.45 Theoretical frameworks over centuries started with more prominent deontology to consequentialists and utilitarians and to virtue ethics with respective pros and cons. In complex humanitarian contexts that demand more practical approaches and across professions, other philosophies and frameworks were explored and developed, such as legal frameworks (international humanitarian law, refugee law, and justice and conventions); humanitarian principles, codes of conducts, professionalism and competencies; and public health ethics. Humanitarian philosophy with more politically connected theories of rights, beyond charity ethics that often lacks any accountability and is open to abuse, shunned away from basic morality, mixed motives or moral generalisation, and further connected humanitarian values to justice that emphasised the rights set in international humanitarian law and was designed to transform the status of victims or beneficiaries to claimants with giving details about duties.46–48 With equality as a focus, the rights meant to give an integrated moral, political and legal framework of affirming universal human values through protection in the midst of political violence and conflicts, dignity as opposed to patronising, and setting standards for practice and accountability. However, these rights, encroached on legal jargons, were considered utopian, derived from Western social constructs, and often not comprehensible for the actual beneficiaries.46 49 50 They were contested between different cultures and their politics, were perceived as either cultural imperialism or subversive, and often failed to capture diverse but connected moral imaginations such as solidarity, compassion and benevolence, and kindness and love as important elements.46 49 50 Similarly, the emphasis on humanitarian principles (neutrality, impartiality and independence) struggled to keep relevance in most important contexts they were designed for, including politically motivated wars and humanitarian situations in Syria, Afghanistan or Yemen, where neutrality and impartiality were neither practical nor conducive at times.51 52

As researchers, we certainly struggled to properly identify what all these philosophies, theories and principles meant in practice for aid workers and beneficiaries. There are limited empirical data to clarify if aid beneficiaries or workers agree or had anything to do with these philosophies. To our understanding, these philosophies and frameworks often failed to resolve pervasive moral and ethical conflicts. At this intersection, we also wondered about the role of humanitarian intervention and its purpose in today’s sociopolitically complicated world, and whether any help or assurance of survival is enough or if there needs to be commitment to change sociopolitical contexts affecting people’s livelihood. This also led us to question the way we should identify needs (whose value, wishes or priorities) and primacies, its governance and the ways to address needs, and the overall pros and cons. In doing so, we found ourselves stepping outside the scope of moral reasoning and domain of ethics. As other scholars discussed, the fundamental contributing factors differ at each ethical decision-making level (macro, meso and micro).29 53 At the macro level, decisions are based on social constructs solidified through complex processes from the individual and institutional value sets, and organisations’ missions and agendas. How can we connect this to the micro level implementer? How much does the proximity of choices matter in the way we perceive them as moral or ethical challenges? The stakeholders’ experiences matter, and they are likely different at each level, irrespective of the moral or ethical underpinnings or social constructionism. Therefore, some scholars suggest going beyond moral and ethical reasoning to transparency and accountability to better address some of the high-level challenges.53

From our point of view, as field workers are closer to the action, the transparency of choices is more vivid and could provide a better chance of assuring accountability irrespective of when it will take place. To investigate this, there is a need to better understand the nature of aid workers’ emotional responses to ethical situations and to explore the deeper value and drive for their work. Career humanitarians developed coping strategies to deal with inequities as they pragmatically refused to be bystanders even if they accepted the inherent cruelties of humanitarian contexts.13 To us, that underlying driving force is justice and fairness, which direct the expression of humanity through proximity, physical solidarity and practical empathy (beyond social media clicktivism) and encompasses transparency and resultant accountability as modes to achieve justice. Not surprisingly, however, broader questions emerged: is, should or will humanitarian assistance be just or fair to accompany this drive? If fair, then to whom, how and based on whose value determination in a given context or situation? Why do career humanitarians care about justice and fairness? What are internal factors unique to this self-selected group? Why is it important to do right at all times and fix everything that is wrong with the aid system? Possibly, some of these challenges could be perceptions, as there is no direct input from aid’s beneficiaries, hence the idea of moral superiority that falls beyond the scope of this paper.

Nevertheless, there is an inevitability of emotional and moral distress in humanitarian settings which we hypothesise is from a natural instinctual desire to protect humanity and human dignity. Looking for a silver lining, we suggest that for humanitarian workers, there is an attempt to bring good consequences to a horrible situation at some point, through some form of accountability or collective responses. Humans, we hypothesise, reflect not only on inevitable death or suffering itself but also the way we respond to that loss or suffering. To us, that is where moral distress arises, primarily as an appropriate response for individuals, their family or community, or others who somehow resemble victims. Therefore, our ability and commitment to care, show compassion and exercise humanity are a deeper way to mourn and profoundly respond to these losses and to avoid them in the future, as a greater purpose of human survival, which connects to accountability and resultant justice. We conclude that this deep desire to rectify most unjust situations is a naturally selected instinctual strategy that cannot possibly be ignored.

Our participants were not representative of the entirety of aid workers. We had no information about the beneficiaries’ ethical experiences and views. We only aimed to explore this overarching dialogue holistically to the next level. We therefore rely on readers and scholars to help further this discussion.