Newborns in crisis: An outline of neonatal ethical dilemmas in humanitarian medicine.

Newborn infants are among those most severely affected by humanitarian crises. Aid organisations increasingly recognise the necessity to provide for the medical needs of newborns, however, this may generate distinctive ethical questions for those providing humanitarian medical care. Medical ethical approaches to neonatal care familiar in other settings may not be appropriate given the diversity and volatility of humanitarian disasters, and the extreme resource limitations commonly faced by humanitarian aid missions. In this paper, we first systematically review existing guidelines relating to the treatment and resuscitation of newborns in humanitarian crises, finding little substantive ethical guidance for those providing humanitarian healthcare. We next draw on paradigm cases and published literature to identify and describe some of the major ethical questions common to these settings. We divide these questions into quality of life considerations, allocation of limited resources, and conflicting cultural norms and values. We finally suggest some preliminary recommendations to guide ethical decision-making around resuscitation of newborns and withdrawal of treatment in humanitarian settings.

Ethical Challenges in the Provision of Mental Health Services for Children and Families During Disasters.

PURPOSE OF THE REVIEW: As mental health professionals assist individuals and communities affected by disaster, they are likely to encounter ethical issues. We conducted a review of academic and grey literature to identify ethical issues associated with the provision of mental health care during disasters, with particular attention to children and families. RECENT FINDINGS: We identified nine categories of ethical challenge: ensuring competent care; protecting confidentiality and privacy; obtaining informed consent and respecting autonomy; providing culturally sensitive care; avoiding harm; allocating limited resources; maintaining neutrality and avoiding bias; addressing issues of liability and employer responsibilities; and conducting research ethically. The organization and provision of mental health services during disasters presents ethical challenges for care providers-as well as for communities, coordinators, and policymakers. Mental health professionals need to navigate this ethical terrain in order to provide needed care to individuals and communities affected by crisis.

Otolaryngology in Low-Resource Settings: Practical and Ethical Considerations.

Providing otolaryngology care in low-resource settings requires careful preparation to ensure good outcomes. The level of care that can be provided is dictated by available resources and the supplementary equipment, supplies, and personnel brought in. Other challenges include personal health and safety risks as well as cultural and language differences. Studying outcomes will inform future missions. Educating and developing ongoing partnerships with local physicians can lead to sustained improvements in the local health care system.

Ethical questions identified in a study of local and expatriate responders' perspectives of vulnerability in the 2010 Haiti earthquake.

BACKGROUND: Situations of disaster that prompt international humanitarian responses are rife with ethical tensions. The 2010 Haiti earthquake caused great destruction and prompted a massive humanitarian response. The widespread needs experienced by the population and the scale of the response inevitably rendered priority-setting difficult, and gave rise to ethical challenges. PURPOSE: This paper presents four ethical questions identified in the analysis of a study on vulnerability and equity in the humanitarian response to the 2010 Haiti earthquake. METHODS: Using interpretive description methodology, the interdisciplinary research team analysed 24 semi-structured in-depth interviews conducted with expatriate and Haitian health workers and decision-makers involved in the response. RESULTS: Ethical questions identified through the analysis were: (1) How should limited resources be allocated in situations of widespread vulnerability and elevated needs? (2) At what point does it become ethically problematic to expend (considerable) resources to sustain expatriate disaster responders? (3) How ought rapid and reactive interventions be balanced with more deliberated and coordinated approaches? (4) What trade-offs are justified when interventions to address acute needs could contribute to long-term vulnerabilities? DISCUSSION: The questions arise in light of an immense gap between available resources and widespread and elevated needs. This gap is likely unavoidable in large-scale crises and may be a source of ethical distress for both local and international responders. The analysis of ethical questions associated with crisis response can advance discussions about how relief efforts can best be designed and implemented to minimise ethical distress and improve assistance to local populations.

Ethics of emergent information and communication technology applications in humanitarian medical assistance.

New applications of information and communication technology (ICT) are shaping the way we understand and provide humanitarian medical assistance in situations of disaster, disease outbreak or conflict. Each new crisis appears to be accompanied by advancements in humanitarian technology, leading to significant improvements in the humanitarian aid sector. However, ICTs raise ethical questions that warrant attention. Focusing on the context of humanitarian medical assistance, we review key domains of ICT innovation. We then discuss ethical challenges and uncertainties associated with the development and application of new ICTs in humanitarian medical assistance, including avoiding harm, ensuring privacy and security, responding to inequalities, demonstrating respect, protecting relationships, and addressing expectations. In doing so, we emphasize the centrality of ethics in humanitarian ICT design, application and evaluation.

The Chennai floods of 2015 and the health system response.

The Chennai floods of 2015 were a calamity of unexpected proportions (1). The impact on the lives of the poor has been immense. Thousands needed to abandon their already precarious dwellings on the banks of the Adyar River, and other low-lying areas for temporary shelters. The differential experience and impact of disasters on different segments of the population helps understand the dynamics of sociopolitical structures and supports.

The Chennai floods of 2015: urgent need for ethical disaster management guidelines.

India has suffered several natural disasters in recent years. The super cyclone of Orissa in 1999 and the tsunami on the southeastern coast in 2004, both led to major developments in disaster management abilities in the country. Almost a decade after the last major disaster that hit south India, the recent floods in Chennai in 2015 brought to the fore a whole set of ethical considerations. There were issues of inequity in the relief and response activities, conflicts and lack of coordination between the government and non-government relief and response, more emphasis on short-term relief activities rather than rehabilitation and reconstruction, and lack of crisis standards of care in medical services. This paper highlights these ethical issues and the need for ethical guidelines and an ethical oversight mechanism for disaster management and response.

[The Humanitarian Charter and minimum standards in humanitarian response are applicable in German refugee facilities]. / Gültigkeit international verbindlicher, normativer und technischer Standards der Flüchtlingshilfe auch in den deutschen Erstaufnahmeeinrichtungen.

BACKGROUND: In recent refugee migration into Germany the responsibilities and reactions of health authorities are still lacking general co-ordination. PROBLEM: Can the ethical and technical standards of international humanitarian assistance serve as an appropriate and even a compulsory guideline for relief agencies, public health and regulatory authorities in Germany? METHODS: Documents from the field of medical ethics, medical law, international humanitarian law and disaster medicine will be examined and checked for practicability by consulting experiences during the 1990s Balkan wars refugee movement and international missions of relief agencies. RESULTS: Ethical and technical standards of international humanitarian assistance have been developed, improved and evaluated for 20 years, and are valuable tools for emergency management. CONCLUSIONS: Victims of disaster or conflict have a right to live in dignity and therefore have a right to receive health care according to international standards. International ethical and technical standards for refugees should be considered in the Federal Republic of Germany like in any other country.

The problem with rescue medicine.

Is there a rational and ethical basis for efforts to rescue individuals in dire straits? When does rescue have ethical support, and when does it reflect an irrational impulse? This paper defines a Rule of Rescue and shows its intuitive appeal. It then proceeds to argue that this rule lacks support from standard principles of justice and from ethical principles more broadly, and should be rejected in many situations. I distinguish between agent-relative and agent-neutral reasons, and argue that the Rule of Rescue qualifies only in a narrow range of cases where agent-relative considerations apply. I conclude that it would be wise to set aside the Rule of Rescue in many cases, especially those involving public policies, where it has only weak normative justification. The broader implications of this analysis are noted.

Mandatory evacuation of residents during the Fukushima nuclear disaster: an ethical analysis.

BACKGROUND: The Japan earthquake and tsunami of 11 March 2011 severely damaged the Fukushima Daiichi nuclear plant. After learning of the radiation leak, the Japanese government issued an evacuation directive for residents within 20 km of the plant a day after the earthquake. Approximately 1 month later, this area was designated a 'high alert zone' and effectively sealed-off. The purpose of this report is to examine these measures from an ethical perspective, and consider what lessons can be drawn from this experience. METHODS: Analytic discussion. RESULTS: We examine the measures from an ethical perspective and argue that if the government's aim was to avoid health risks posed by radiation exposure, then ordering compulsory expulsion of all residents cannot be ethically justified. We assert that the government may not have ordered the mandatory evacuation solely based on health risks, but rather to maintain public order. CONCLUSION: Careful scrutiny of the case revealed that this public health intervention involved an objective completely unrelated to public health, and that disguising these policies using the reasonable and acceptable purpose of public health made it easier to justify undue restriction of individual liberty.

Preventing corruption in humanitarian assistance: perceptions, gaps and challenges.

Corruption is a threat to the purpose of humanitarian assistance. Until fairly recently, humanitarian assistance has not been considered an important arena in broader efforts aimed at curbing corruption, and corruption has not always been considered a particularly important concern for humanitarian assistance despite the obviously challenging nature of the context of humanitarian emergencies. Corruption, though, is a threat to humanitarian action because it can prevent assistance from getting to the people who most need it, and because it can potentially undermine public support for such assistance. This paper examines perceptions of corruption and its affects, documents best practices, and outlines gaps in understanding. It suggests recommendations for improving the capacity of humanitarian agencies to prevent and manage the risk of corruption. Agencies have taken steps to combat corruption and improve accountability--downwards and upwards--but scope remains for improvement and for greater sharing of learning and good practice.

Debating life after disaster: charity hospital babies and bioscientific futures in post-Katrina New Orleans.

In Louisiana's unique, populist-derived charity health system, the self-designation Charity Hospital Baby expresses situational identity anchored in the life cycle and the inversion of racist and authoritative connotations. This article draws on theoretical perspectives of stratified reproduction and the politics of time to examine the controversy in which Babies advocate reopening the Katrina-damaged New Orleans Charity Hospital, and administrators and planners support a new state-of-the-art biosciences district, GNOBED. Babies evoke the present, ethical urgency (kairos) of responding to sickness and disability; GNOBED implies prolonging or saving future lives through biotechnologies under development in accelerated time (chronos). As preservationists and residents threatened with displacement join "re-open Charity" proponents, planners symbolically engage in prolepsis, rhetorically precluding opposing arguments with flash forward of supposedly "done deals." At stake is nothing less than social death for a segment of this ethnically diverse city. [public

[Humanitarian ethics and the concept of justice]. / L'ethique humanitaire et la notion de justice.

The bases of humanitarian assistance, beyond a legal norm--which appears to be essential given the inalienable obligations that result for all participating bodies--are influenced by philosophical and political conceptualizations framed in an ethics of justice. Actors in the humanitarian field who adhere to the Rawlsian social contract model their actions based on a philosophy that assistance is a noble and desirable option that remains in the hands of those who offer aid, and who can freely choose to not offer such assistance. Peter Singer and Thomas Pogge propose nuances to the understanding of the duty of assistance. Not assisting would be bad, basically tantamount to killing. Assistance is no longer a caring act deserving of praise, but rather a moral obligation. The financial imperatives of associations, the growing complexity of activities and the development of an important element of communication lead to a professionalization of humanitarian medicine. A modern vision of humanitarian assistance requires an understanding of justice and solidarity and global outreach. We believe that ethics need to be embedded firmly in humanitarian actions that have clear political implications.

Lessons from the Chilean earthquake: how a human rights framework facilitates disaster response.

The earthquake of 2010 in Chile holds important lessons about how a rights-based public health system can guide disaster response to protect vulnerable populations. This article tells the story of Chile Grows With You (Chile Crece Contigo), an intersectoral system created three years before the earthquake for protection of child rights and development, and its role in the disaster response. The creation of Chile Grows With You with an explicit rights-oriented mandate established intersectoral mechanisms, relationships, and common understanding between governmental groups at the national and local levels. After the earthquake, Chile Grows With You organized its activities according to its founding principles: it provided universal access and support for all Chilean children, with special attention and services for those at greatest risk. This tiered approach involved public health and education materials for all children and families; epidemiologic data for local planners about children in their municipalities at-risk before the earthquake; and an instrument developed to assist in the assessment and intervention of children put at risk by the earthquake. This disaster response illustrates how a rights-based framework defined and operationalized in times of stability facilitated organization, prioritization, and sustained action to protect and support children and families in the acute aftermath of the earthquake, despite a change in government from a left-wing to a right-wing president, and into the early recovery period.

Denial of flood aid to members of the Ahmadiyya Muslim community in Pakistan.

During the catastrophic floods of 2010 in Pakistan, approximately 500 internally displaced families belonging to the Ahmadiyya sect of Islam were denied humanitarian relief. The failure of international agencies and Pakistan's government to protect basic human rights in the context of disaster relief raises profound questions. If all humanitarian work associated with natural disasters must be governed by canons of human rights, how should international agencies deal with legally empowered official discrimination? A review of the history of the Ahmadiyya community in Pakistan reveals decades of state-sanctioned persecution, particularly through its anti-blasphemy laws, and poses a serious challenge to the international community. When effective intervention is predicated on cooperation with state institutions, how can international relief agencies avoid becoming implicated in official discrimination? The denial of flood aid to Pakistan's Ahmadiyya community highlights the need for concerted action in disaster settings to prevent discrimination against vulnerable groups. Discriminatory legislation is not only a violation of basic norms enshrined in international compacts, it is a key problem for disaster relief.

Livelihoods and protection in situations of protracted conflict.

This paper presents the findings from research on livelihoods-protection linkages from the perspective of conflict-affected populations as well as agency analysis and action. The aim of the research is to understand how greater complementarity between humanitarian protection and livelihoods approaches might reduce the risks facing conflict-affected populations. The findings show that the causes of risks to livelihoods and protection are often the same, and that community responses are intimately connected, providing good rationale for linking operational approaches. There are four main ways in which this can be done. First, by targeting those confronting the greatest risks. Second, by addressing the causes of risks through advocacy and capacity-building. Third, by implementing livelihoods interventions that minimise the need to adopt unsafe livelihood strategies and that address humanitarian consequences. Fourth, by making sure that livelihoods programming does not pose additional risks.

Forced displacement and women's security in Colombia.

In the protracted Colombian conflict, assistance to internally displaced persons has developed in the context of contradictory political processes. The Colombian government's launching of a transitional justice process in the midst of armed conflict has generated a complex situation displaying both conflict and post-conflict characteristics. The progressive Constitutional Court rulings on internal displacement, in particular the gender-sensitive Auto 092, constitute an attempt to bring together humanitarian interventions and transitional justice measures in a rights-based framework. However, the national government is reluctant to adopt them fully and local realities still hamper their integrated implementation. Displaced women, therefore, remain in an especially vulnerable position. This paper argues that gender-sensitive humanitarian interventions must take into account all of these complexities of scale and political process in order to make legal frameworks more effective at the local level. In these contexts, interventions should pay particular attention to strategies that contribute to transforming pre-existing gender regimes.