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R E S E A R C H A R T I C L E Open Access
Challenges to ethical obligations and
humanitarian principles in conflict
settings: a systematic review
Grant Broussard
1
, Leonard S. Rubenstein
2,8
, Courtland Robinson
1
, Wasim Maziak
3,4
, Sappho Z. Gilbert
5
and
Matthew DeCamp
6,7*
Abstract
Background: Humanitarian health care organizations and health workers working in contexts of armed or violent
conflict experience challenges in fulfilling ethical obligations and humanitarian principles. To better understand the
types of challenges experienced in these contexts, we conducted a systematic literature review.
Methods: A broad search strategy was developed for English language publications available in PubMed, Ovid/
EMBASE, and Scopus. The search relied upon three key concept blocks: conflict settings, humanitarian or relief
organizations, and non-clinical or non-military ethics. To be included, publications had to (1) refer implicitly or
explicitly to ethics and/or humanitarian principle(s), (2) relate to non-military relief work in active conflict or conflict-
affected settings, (3) relate to organizational mission and/or delivery of services, and (4) relate to events after 1900.
Records were qualitatively analyzed using an emergent thematic analysis approach that mapped challenges onto
recognized ethical obligations and humanitarian principles.
Results: A total of 66 out of a possible 2077 retrieved records met inclusion criteria. The most frequently noted
ethical challenges for organizations working in conflict settings were (1) providing the highest attainable quality of
care, (2) protecting workers, and (3) minimizing unintended harms. The humanitarian principle most frequently
noted as challenging to uphold was neutrality (the duty that humanitarian actors must not take sides in a conflict).
Ethical challenges and humanitarian principles were commonly co-coded. For example, the challenge of providing
the highest attainable quality of care frequently intersected with the humanitarian principle of humanity.
Conclusions: By categorizing the types of ethical challenges experienced by humanitarian care organizations, this
review can help organizations anticipate issues that might arise in conflict settings. The identified relationships
between ethical challenges and humanitarian principles suggests that frameworks and guidance for ethical
decision-making, if adapted for conflict settings, could support organizational capacity to fulfill ethical and
humanitarian commitments.
Keywords: Aid, Conflict, Ethics, Health, Humanitarianism, Violence
© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made.
* Correspondence: matthew.decamp@cuanschutz.edu
6
Berman Institute of Bioethics and Division of General Internal Medicine,
Johns Hopkins University, Baltimore, USA
7
Current affiliation: Center for Bioethics and Humanities and Division of
General Internal Medicine, University of Colorado, Mailstop B137, 13080 E.
19th Avenue, Aurora, CO 80045, USA
Full list of author information is available at the end of the article
Journal of International
Humanitarian Action
Broussard et al. Journal of International Humanitarian Action (2019) 4:15
https://doi.org/10.1186/s41018-019-0063-x
Introduction
Humanitarian health organizations and health workers
frequently work in conflict settings where they are subject
to direct attack and where active armed conflict disrupts
basic institutions and provision of services. Violence
against humanitarian health workers, which may result in
death, is a persistent and pervasive contemporary problem
(Humanitarian Data Exchange (HDX) 2019;Safeguarding
Health in Conflict Coalition (SHCC) 2018). Syria, in par-
ticular, has been called “the most dangerous place on
earth for health-care providers”(Fouad et al. 2017).
Violent attacks against humanitarian health organiza-
tions and workers have many negative consequences.
Health workers may suffer bodily injury, psychological
harm, economic loss, and even death. Attacks can
destroy hospitals and other facilities, disrupt delivery of
essential supplies, interrupt service provision, and/or
cause an organization to leave. Violent attacks can also
discourage extending humanitarian assistance to where
it is most needed.
Violent attacks not only violate international law
(Rubenstein and Bittle 2010); they also create ethical
challenges (Slim 2015). Health workers functioning in
conflict settings may be faced with sudden and difficult
decisions, including whether to practice outside their
scope of training because of personnel shortages, how to
deliver care when resources are limited or unreliable,
which patients to treat when resource or security con-
straints prevent equal access, and how to maintain im-
partiality in providing care to both the victims and
perpetrators of attacks, among many others. Humanitar-
ian health care organizations face similarly challenging
ethical issues, such as whether to rebuild destroyed facil-
ities in more remote locations (which may negatively
affect access), whether to focus special attention and
resources in reaching vulnerable groups (when doing so
might be detrimental to serving the most people pos-
sible), how much risk they can allow for their workers,
and how to remain independent in the face of demands
by combatants and donors.
Nevertheless, the full range of ethical and humanitar-
ian challenges experienced by humanitarian health orga-
nizations—especially in conflict settings—has not been
described. Understanding that range is essential for de-
veloping strategies to better manage them, but existing
systematic reviews have not focused on ethical issues
specifically (Chaudhri et al. 2019). In addition, whether
existing frameworks for ethical decision-making in hu-
manitarian action (Clarinval and Biller-Andorno 2014;
Fraser et al. 2015) might apply or be useful in settings
where health care workers and facilities are themselves
subject to persistent attack remains unknown. To begin
filling these knowledge gaps, we conducted a systematic
literature review of the ethical and humanitarian
challenges experienced by humanitarian health organiza-
tions in conflict settings. This systematic review is part
of a larger project examining (via interviews and work-
shops) the organizational- and individual-level ethical
challenges that humanitarian organizations have faced
during the Syrian conflict.
Methods
Search strategy
Working with a research librarian, we developed a broad
search strategy utilizing three core concept blocks: (1)
conflict, (2) humanitarian or relief organizations, and (3)
non-clinical or non-military ethics. We chose search
terms for each concept block using controlled vocabu-
lary and key terms with iterative search yield analyses.
The first concept block included 13 search terms:
“conflict,”“war,”“wars,”“warfare,”“revolution,”“revolu-
tions,”“Arab spring,”“uprising,”“uprisings,”“cruelty,”
“cruelties,”or “high-risk environments.”The second
block consisted of seven search terms: “relief,”“relief
work,”“aid,”“humanitarian,”“humanity,”“NGO,”or
“NGOs.”The third block included nine search terms:
“ethics,”“ethical,”“morality,”“professionalism,”“profes-
sional duties,”“neutrality,”“principles,”“independence,”
and “accountability.”The full search strategy can be
found in Additional file 1: Appendix 1.
Screening process
Three databases were searched: PubMed, Ovid/EMBASE,
and Scopus. The searches returned 442 records in
PubMed, 699 in Ovid/EMBASE, and 929 in Scopus. Titles
and abstracts were independently screened by two study
team members. To be included for full-text review,
publications had to have an available full-text version, be
published in English, and address all three key concept
blocks. Publications that described only clinical ethics
issues (e.g., truth telling or informed consent) that were
not strictly related to a conflict setting were excluded; this
ensured a consistent focus on those issues salient to, and
arising in, conflict settings. Similarly, we excluded military
ethics as not germane to humanitarian practice.
During full-text review, we applied the following inclu-
sion criteria. To be included in qualitative analysis, a
publication needed to (1) include reference, implicitly or
explicitly, to ethics and/or humanitarian principle(s); (2)
relate to non-military relief work in active conflict or
conflict-affected settings; (3) relate to organizational
mission and/or delivery of services; and (4) relate to
events occurring in the twentieth century or later. To
supplement the database searches, we also reviewed the
reference lists of included publications. Disagreements
about inclusion between the two initial reviewers were
adjudicated by one or more additional study team
member(s).
Broussard et al. Journal of International Humanitarian Action (2019) 4:15 Page 2 of 13
Data coding and abstraction
Two study team members qualitatively analyzed the in-
cluded articles using a thematic editing style (Campbell
et al. 2011). Data were managed using NVivo software
(QSR International Pty Ltd., Version 11.x, 2017).
First, a preliminary codebook was developed based on
an informal review of the literature (Additional file 1:
Appendix 2), the research team’s experience and
knowledge of the field, and consultation with experts in
related areas of humanitarian ethics research, such as
ethical issues that emerged in responding to the 2014–
2015 Ebola epidemic. This preliminary codebook
included two primary categories (i.e., “Ethical obliga-
tions”and “Humanitarian principles”). Within these cat-
egories, nodes were created to accommodate specific
obligations and principles; within these nodes, subnodes
were created to capture specific challenges to fulfilling
the obligations and principles.
The “ethical obligations”category drew upon existing
literature on ethical issues for humanitarian organiza-
tions and humanitarian health practice generally, in pan-
demics (e.g., influenza and Ebola [Kass et al. 2019]), in
conducting research on sexual violence in emergency sit-
uations, and other areas (see Additional file 1: Appendix
2). Although ethical obligations of humanitarian health
organizations and health workers may overlap, the focus
of the codebook was the organizational level.
The “humanitarian principles”category drew upon the
four widely accepted humanitarian principles: neutrality,
impartiality, humanity, and independence (General
Assembly resolution 46/182 1991; General Assembly reso-
lution 58/114 2004; Pictet 1979;SphereProject2011).
Neutrality is the duty that humanitarian actors must not
take sides in a conflict. Impartiality stipulates that humani-
tarian actors must not discriminate or give preference to
any nationality, race, religious belief, class, affiliation, or
political opinion. Humanity means that human suffering
must be addressed wherever and for whomever it is found.
Independence demands that humanitarian actors retain
their autonomy and remain independent of political or
military objectives of other actors.
By employing these two main categories, we do not
mean to imply that humanitarian principles and ethical
obligations are fundamentally different in kind; at a high
level, both are normative (i.e., they indicate what should
or ought to be done). Our decision to differentiate them
for analysis was motivated by three considerations. First,
humanitarian principles and ethical obligations have
different descriptive origins. Humanitarian principles
originated more recently in operational, legal, and ethical
frameworks for the Red Cross movement in its humani-
tarian activities; they have since been adopted by the
United Nations and humanitarian organizations. Two of
the principles, humanity and impartiality, provide what
has been called “a moral ideal”for humanitarian action,
while neutrality and independence are “practical tools
for making humanity and impartiality a reality”(Labbé
and Daudin 2016). Second, based on our initial literature
review, the humanitarian and ethics literatures infre-
quently connect to each other; one goal of our review
was to elucidate those connections in the peer-reviewed
literature. Third, in practice humanitarian organizations
and workers may view and use humanitarian principles
and ethical obligations differently; this assumption was
later borne out in workshops we conducted as part of
the larger project. In these workshops, for example,
attendees viewed humanitarian principles more as
motivating ideals, whereas ethical obligations were
viewed as more specifically action-guiding.
Second, the preliminary codebook was used by two
study team members to review ten randomly selected
full-text articles. After independently reviewing the arti-
cles, the study team members met to discuss and resolve
category coding differences. At this stage, two major
additions were made to the codebook. In the “ethical ob-
ligations”category, the obligation of appropriate acquisi-
tion and management of assets (including financial,
material, and human assets) was added as a node
(Civaner et al. 2017; Hunt 2008). In the “humanitarian
principles”category, the principle of “solidarity”was
added as a node, as it was noted to be an emerging hu-
manitarian principle. In the literature, solidarity has been
defined in different ways to include concepts of political
advocacy, human rights, shared suffering, and consult-
ation with those affected (Hunt et al. 2014; Hurst et al.
2009; Omaar and de Waal 1994; Slim 1997a,b). In light
of solidarity being a more recently emergent principle
lacking a single standard definition in the literature, for
the purposes of coding, we employed a broad conception
of solidarity that encompassed all of these possible uses.
Third, the two study team members used the revised
codebook to re-code the same ten articles, and results
were compared. The comparison revealed differences re-
lated to length of text coded and frequency of coding,
but not the presence or absence of nodes. Satisfied with
the reliability of coding, the two study team members
proceeded to independently code the remaining articles.
Text passages were coded line-by-line using this scheme.
Passages that were difficult to interpret were discussed
and coding was reconciled through discussion among
the entire study team.
The two primary categories were not mutually exclu-
sive. Given the nature of our subject matter—ethics and
humanitarian principles in conflict settings—and our
goal to describe and categorize the range of issues
arising, we did not assess the “quality”of included
articles overall or of any specific statements or
arguments presented.
Broussard et al. Journal of International Humanitarian Action (2019) 4:15 Page 3 of 13
Results
This search yielded 2077 records. After 451 duplicates
were removed, and 1537 records were excluded during
abstract and title review, 89 articles were selected for
full-text review. Of these, 23 did not meet inclusion
criteria. Reference list review yielded an additional seven
publications. In total, 66 articles met inclusion criteria
and were included in the analysis (see Fig. 1for the
study flow diagram and Additional file 1: Appendix 3 for
the list of 66 included articles).
A full summary table of qualitative findings with rep-
resentative quotations can be found in Additional file 1:
Appendix 4. Below, we present key summary findings. In
reporting numbers, “N”refers to the total number of
articles with the code applied, and “n”refers to the
number of individual coding instances (i.e., a single
article could include multiple coding instances).
Ethical obligations
Table 1presents findings related to ethical obligations.
The organizational ethical obligation most frequently
coded was providing the highest attainable quality of
care and services. This obligation was discussed in 52/66
(79%) of sources and was also the most frequently
assigned code. Challenges to fulfilling this obligation
included disruption in available supplies and services,
difficulty getting supplies and services to the front lines
(even when they were available), and a perceived lack of
accountability for quality of care (e.g., documented
impact, quality reporting, and so on).
Appropriate acquisition and management of assets
(i.e., informational, financial, and human assets) was an
ethical obligation that emerged in the analysis. This
obligation operated at the organizational management
level (e.g., when an organization faces difficulties in
maintaining a stable workforce).
The third most frequently coded obligation related to
protecting and caring for workers (i.e., the “duty to care”
in the humanitarian literature). The duty to care can be
a legal obligation that employers must meet regarding
their employees. In humanitarian settings and more
broadly from the standpoint of ethics, it more commonly
refers to the recognized ethical obligation of organiza-
tions to foresee, prepare for, and mitigate the impacts of
working in a complex, stressful, and sometimes danger-
ous environment. A particular challenge related to this
obligation was concern over “risk transfers,”or situations
where organizations might seek to mitigate their own
Fig. 1 Search flow diagram
Broussard et al. Journal of International Humanitarian Action (2019) 4:15 Page 4 of 13
risks or risks to their workers by transferring them to
others (e.g., by assigning certain tasks to local individuals).
Humanitarian principles
Table 2summarizes findings related to humanitarian
principles evident in the literature reviewed. Neutrality
was coded most frequently. A significant challenge to
neutrality was the idea that aid itself could be perceived
as political. For example, when an aid organization
works closely with a local population, that association
could be perceived as compromising neutrality if the
local population is perceived to be on one side of the
conflict.
Challenges to the principle of independence were also
prevalent. For example, organizations’commitments to
independence could come into question due to political
or financial ties with state agencies, non-state groups, or
donors that might restrict an organization’s activities,
even if these ties were merely perceived. Non-
transparency related to budgetary or programmatic
decision-making was another commonly coded situation
where independence could be in question.
Regarding impartiality, pressure on organizations to
show favoritism to one group over another was the most
frequent subnode. For example, some sources described
situations where organizations were forced to choose
between losing access to an entire population or yielding
to demands of armed groups to give preferential
treatment to their members. Even without this type of
overt pressure, humanitarian health organizations could
sometimes be compelled to concentrate aid work in safe
or more easily accessible areas.
The intersection of ethics and humanitarian principles
As described in our methods, coding of humanitarian
principles and ethical obligations was not mutually
Table 1 Coding frequencies of ethical obligations, including the top coded challenges
Discrete ethical obligations (nodes) Sources Coding instances
•Challenges to their fulfillment (subnodes)
Provide highest attainable quality of care and services 52 301
•Disruption of supplies and services
•Difficulty getting supplies and services to the front lines
•Poor quality due to lack of accountability for care quality
Appropriate acquisition and management of assets 43 264
•Difficulty securing and protecting informational assets
•Mismanagement other difficulties with financial assets
•Problems with recruitment, effective retention strategies, and fair
management practices of human assets (e.g., emigration of skilled workers)
Protect and care for health workers 44 237
•Direct attacks on facilities and/or workers
•Inability to make contingency or safety plans
•“Risk transfers”(i.e., when international or non-local actors transfer dangerous
and/or risky assignments to local workers and volunteers)
Support a locally led response 45 149
•Lack of trust in the local authorities
•Difficulty in identifying a local leader/partner
Distribute benefits and burdens equitably 39 118
•Inability to access the most vulnerable populations
•Perceived pressure to preferentially care for certain groups
Incorporation of local knowledge and recognition of cultural norms 30 112
•Multiple social groups with differing cultural norms
•Urgency makes respecting cultural norms impractical
Minimize harms of response 35 106
•Inability to accurately measure or estimate harms
Honesty and transparency in communication and interactions 17 47
•Risk perceived in being transparent (e.g., subjecting facilities to future
attacks by publicizing locations)
Broussard et al. Journal of International Humanitarian Action (2019) 4:15 Page 5 of 13
exclusive. Table 3displays the frequency of co-coding
these two categories; Table 4illustrates this intersection
with five examples.
In some instances, this intersection was found to
represent apparent tension between fulfilling humani-
tarian principles and ethical obligations. For example,
the ethical obligation to support a locally-led response
could be in tension with the humanitarian principle
of independence when local community members are
aligned with one side of the conflict or another. Simi-
larly, the ethical obligation to provide honest and
transparent communication could be in tension with
the principle of independence, for example, if distrib-
uting communication relies upon state-owned media.
In other instances, this intersection was found to be
mutually supportive. For example, the ethical obliga-
tion of ensuring a fair distribution of the benefits and
burdens of aid supports fulfilling the humanitarian
principle of impartiality.Weexploretherelationship
between ethical obligations and humanitarian princi-
ples further in the “Discussion”section.
Management strategies
While not the focus of our review, coders did make
note of strategies organizations used to attempt to
manage identified challenges. Without endorsing these
as the best or only correct strategies, these are listed in
Additional file 1: Appendix 4. We highlight several here.
Some organizations have responded to the obligation
to protect workers, for example, by creating secure
operational sites with minimal and/or strictly controlled
access to the outside world (a strategy known as
“bunkerization”). Such a strategy can protect workers,
but may occur at the expense of another obligation, i.e.,
involving locals in operational planning and manage-
ment. By contrast, for example, some organizations have
created formal decision-making processes inclusive of all
stakeholders, including aid recipients, for the sake of
transparency and to facilitate incorporation of local
knowledge and norms. Regarding humanitarian princi-
ples, for instance, some organizations have maintained
independence by refusing to accept funds conditional
upon particular program changes or by investing and
Table 2 Coding frequencies of humanitarian principles, including the top coded challenges
Individual humanitarian principles (nodes) Sources Coding instances
•Challenges to their fulfillment (subnodes)
Neutrality 48 283
•Aid can itself be perceived as political
•Tension between witnessing and reporting violence and remaining neutral
Independence 44 205
•Funding sources and connections perceived as compromising independence
•Organizations implicated in conflicts due to their having resources
and investments surrounding the conflict
Humanity 44 153
•Inability to reach those known to be in need
Impartiality 40 133
•Pressures on organization to provide assistance not based solely on greatest need
Solidarity 21 29
•Challenges to promoting solidarity, including distrust among stakeholders
or “us”/“them”attitude, among others
Table 3 Intersections between ethical obligations and humanitarian principles
Provide highest
attainable quality of
care and services
Protect and
care for
response
workers
Minimize
harms of
response
Support a
locally led
response
Appropriate
acquisition and
management of
assets
Distribute
benefits and
burdens
equitably
Practice
honesty and
transparency
Incorporate
local
knowledge
and norms
Neutrality n=40 n=26 n=24 n=19 n=10 n=31 n=10 n=15
Independence n=43 n=18 n=23 n=21 n=29 n=24 n=10 n=13
Impartiality n=25 n=9 n=14 n=13 n=9 n=38 n=4 n=12
Humanity n=73 n=17 n=19 n=16 n=28 n=39 n=6 n=8
Solidarity n=4 n=3 n=3 n=3 n=4 n=3 n=1 n=1
Broussard et al. Journal of International Humanitarian Action (2019) 4:15 Page 6 of 13
developing their own asset management strategies to
avoid reliance upon, or sharing assets with, partisan
groups. Such an approach maintains both real and
perceived independence.
Discussion
This systematic review yielded three principal findings
related to ethical and humanitarian challenges experi-
enced by humanitarian health organizations in conflict
settings. First, the relative frequencies of the ethical obli-
gations and humanitarian principles described provide
insight into the types of issues organizations are likely to
encounter. Second, our findings have identified common
ways in which ethical obligations and humanitarian prin-
ciples can be mutually challenged in conflict settings.
Third, by identifying points of overlap between ethical
obligations and humanitarian principles, this review
could motivate exploration of innovative approaches to
Table 4 Examples that illustrate the potential intersection between humanitarian principles and ethical obligations
Intersection Example description Example quotation Emphasis added
Neutrality and highest attainable
quality of care
Delivering high-quality care may not be viewed as
“neutral”in a conflict when delivering that care comes
under the authority of one side or the other.
Once the international community’s resolve to enforce
international law was revealed as a sham, Hutu-
supremacist camp authorities were able to close down
humanitarian space to a point where agencies were
faced with a stark choice: either provide assistance to
refugees under terms set by the camp authorities or get
out. Most agencies chose the former, while continuing
to call for “political action.”Finding accommodation
with camp authorities involved accepting some
diversion of relief goods through the taxation of
beneficiaries by their political masters. (Fennell 1998)
Humanity and highest attainable
quality of care
The goal of relieving the suffering of all in settings of
extreme violence may mean the highest quality of care
cannot be met.
The participants report concern of medical competence
as a potential source of ethical problems. They state
that in general [health care workers] sent to disaster
settings are not properly trained specifically for
disasters…Some of them state that lack of proper
education makes it difficult to be benevolent to victims.
(Civaner et al. 2017)
Independence and supporting a
locally led response
When local groups are on one side or the other of a
conflict, an organization supporting a locally led
response could be perceived as no longer fully
independent.
Armed actors—both state and non-state—will
frequently seek to associate themselves with aid efforts
to enhance their legitimacy in the eyes of affected
people. Agencies cited examples of this in all four
settings [i.e., Afghanistan, South Central Somalia, South
Sudan and Syria]. One agency representative working
in Damascus said that questions about whether the
government could be taking credit or profiting from
the aid effort “keep [them] up at night.”Non-state
armed groups such as IS and Al-Shabaab sought to
associate themselves positively with aid projects, for
instance by turning up at distributions or, in the case of
IS,making a propaganda film about a health clinic.
(Haver 2016)
Impartiality and equity Providing aid to all victims impartially supports the
obligation of an equitable distribution of the benefits
and burdens of aid.
Access can diminish both as a direct result of violence
and as a consequence of the obstacles and conditions
created by militaries, governments, and non-state actors
that hinder the impartial provision of aid. In an effort to
maintain their presence and continue to deliver on
their humanitarian commitments, a number of
humanitarian organisations have strengthened their risk
management capabilities…increasing their access to
affected populations. (Egeland et al. 2011)
Independence and honesty and
transparency
Being honest and transparent about, for example,
witnessed atrocities could be perceived as
compromising independence.
Humanitarian aid workers from Médecins Sans
Frontières (MSF, Doctors Without Borders) were present
in the town before and during its fall. For months
before the genocide, certain headquarters staff
members believed the situation of the “safe area”was
untenable, but the organization refrained from
conducting advocacy in light of the tenuous presence the
aid workers had in the town…In contrast, over the
roughly two weeks that the town was falling and its
inhabitants were targeted and terrorized, the
organization did go to the media with testimony from
its two international staff members. (Fink 2007)
Broussard et al. Journal of International Humanitarian Action (2019) 4:15 Page 7 of 13
meeting these challenges (e.g., by exploring whether
management of ethical challenges could help organiza-
tions better fulfill humanitarian principles).
Ethical obligations and challenges
In our review, the most commonly identified challenges
to providing the highest attainable quality of care and
services involved logistical obstacles such as disruptions
or shortages of food or medical supplies, personnel, or
care services and difficulties getting medicine and pro-
viders to front lines to meet communities’needs. Chal-
lenges to this obligation, founded on the ethical
principle of beneficence, include disparities in the
availability of facilities and supplies in conflict settings as
compared to that of many workers’home contexts
(Baskett 1994; Bernthal et al. 2014; Civaner et al. 2017;
Hunt 2008; Hunt et al. 2014), the existence of counter-
feit or low-quality supplies and medications (Burkle Jr.
et al. 2017; Michael and Zwi 2002), and policies restrict-
ing the administration of care to select populations and
blocking access to certain locations (Al-Moujahed et al.
2017; Civaner et al. 2017; Clarinval and Biller-Andorno
2014; Fouad et al. 2017).
Our findings also highlight an additional dimension to
the duty to provide high-quality care: accountability.
Fulfilling the obligation to provide high-quality care
requires explicit evaluation of outcomes, without which
the quality cannot be assured (Al-Moujahed et al. 2017;
Burkle Jr. et al. 2017; Civaner et al. 2017; Clarinval and
Biller-Andorno 2014; Fouad et al. 2017).
Even when organizations attempt, at a minimum to
meet their duties of beneficence by avoiding causing
harm, they could face challenges in doing so. Organiza-
tions may fear that providing aid could unintentionally
sustain conflicts (Banatvala and Zwi 2000; Black 2003;
Clarinval and Biller-Andorno 2014; Duffield et al. 2012;
Fink 2007; Gardemann 2002; Hunt 2008; Michael and
Zwi 2002; Poffley 2012; Slim 1997a,b). Moreover, there
were concerns that humanitarian aid could destabilize
established in-country health and other support systems
and create unsustainable programs that result in support
gaps when aid programs depart (Hunt 2009; Jaspars and
O'Callaghan 2010; Rieffer-Flanagan 2009). Lack of
training for workers (especially in disaster- or conflict-
specific competencies) was cited as leading to inadequate
or inappropriate care for vulnerable populations and
forcing workers to make ad hoc decisions about triage
and prioritization of patients and treatments—resulting
in suboptimal care (Civaner et al. 2017;Fouad et al.
2017; Joshi et al. 2008).
Challenges related to the appropriate acquisition and
management of assets arose from informational and fi-
nancial factors. For instance, a lack of interorganizational
information sharing (Haver 2016) or an inability to
attain necessary information due to operational restric-
tions (Bernthal et al. 2014) could make it more difficult
to manage material and personnel resources when deliv-
ering aid. Financially, for example, external constraints
related to the need to maintain relationships with exist-
ing and future donors (Cobey et al. 1993; Gastineau
Campos and Farmer 2003; Haver 2016; MacCormack
2007; Weiss 2016) and internal constraints related to the
need to sustain existing programs and staff (Michael and
Zwi 2002) could affect organizations’abilities to adjust
resource management nimbly in response to ever-chan-
ging circumstances (Clarinval and Biller-Andorno 2014;
Hurst et al. 2009; Leaning et al. 2011). The inability to re-
cruit and retain skilled individuals can require organiza-
tions to fill essential staffing gaps with unqualified or
untrained individuals (Fouad et al. 2017)—an action that
could present a challenge to the provision of high-quality
care.
Quality of care and resource management intersected
the ability of organizations to realize an equitable
distribution of benefits and burdens, an obligation of
justice or fairness, and minimizing harms of a response.
For organizations operating amidst resource shortages, in
settings where local health systems have been destroyed,
or with other critical limitations (Al-Moujahed et al. 2017;
Gardemann 2002;Haver2016), it is nearly impossible to
treat all potential beneficiaries equitably or reach those
most in need. Extremely dangerous security situations can
result in providing aid preferentially to those in safer areas
when, ideally, aid should be provided equitably to all and
provided based on need (Clarinval and Biller-Andorno
2014; Egeland et al. 2011;Haver2016; Leaning et al. 2011;
Poffley 2012).
Organizations may also need to be aware of other
sources of differential care that raise ethical concerns.
These can include the personal prerogatives of humanitar-
ian workers themselves (Ben Shahar 1993; Civaner et al.
2017), gaps in situational awareness that allow dishonest
actors to present distorted views of needs (Fegley 2009;
Gardemann 2002;Haver2016;H
untetal.2014), and
threats of violence or criminal prosecution against health
workers (Blair 1996; Fouad et al. 2017; Haver 2016).
Protecting and caring for health workers (i.e., the “duty
to care”) is another recognized obligation of humanitar-
ian organizations. Advancements in operational security
(Egeland et al. 2011) and a growing acceptance of
increased danger in humanitarian endeavors (Duffield et
al. 2012) may expand the breadth of humanitarian
efforts in conflict settings, making this obligation ever
more central. There is a growing appreciation of the
organizational responsibility to protect its workers and
acknowledgement of the diminished ability to provide
quality care due to security concerns when organizations
operate within conflict settings (Asgary 2015; Banatvala
Broussard et al. Journal of International Humanitarian Action (2019) 4:15 Page 8 of 13
and Zwi 2000; Fouad et al. 2017). There is also a recog-
nized need to ensure that health workers are adequately
informed about these risks. To be sure, the obligation to
protect workers is not the humanitarian organization’s
alone; the international community, via international
humanitarian law, also plays a role in protecting hu-
manitarian health workers (Burkle Jr. et al. 2017; Fennell
1998; Fouad et al. 2017; O'Callaghan and Leach 2014).
Our review identified a specific ethical concern
regarding one way organizations might protect their own
workers: “risk transfers.”Risk transfers, which occur when
international or non-local actors transfer dangerous
assignments to individuals outside their organization,
usually to local actors (thereby meeting another ethical
obligation regarding involving local communities), could
meet the organization’s obligation to protect its own
workers at the expense of others’safety (Egeland et al.
2011). Yet the ethical appropriateness of this practice has
been to date underexplored.
Supporting a locally-led response is an obligation based
on the idea of fair decision-making processes. The col-
lapse of in-country health systems (Al-Moujahed et al.
2017; de Waal 2010; Michael and Zwi 2002); difficulty in
identifying and trusting local leaders (Black 2003; Cobey
et al. 1993; Fouad et al. 2017; Haver 2016; Weiss 2016);
and tensions arising between organizational, individual,
and local beliefs and norms (Civaner et al. 2017; Egeland
et al. 2011; Fegley 2009; Fraser et al. 2015) all make
fulfilling this obligation challenging.
Practicing honesty and transparency in communica-
tions was an important theme in our review. A notable
challenge to honest communication was the perception
that open communications could subject organizational
assets to additional risks (e.g., by subjecting them to
further attacks) (Redwood-Campbell et al. 2014).
Relationships among ethical obligations and challenges
Although the relationship between different ethical
obligations was not typically explicit in the literature, we
noted how ethical obligations could be either in tension
or mutually supportive.
Regarding tensions, for example, the duty to provide the
highest quality care (which could require significant re-
sources) could be in tension with the duty to humanity,
i.e., to relieve suffering wherever it was found (which could
require devoting fewer resources but to more individuals
in need). It is also possible that meeting some obligations,
such as those regarding open communications, locally-led
responses, and respecting cultural norms, could
require dedicated resources and deliberate planning
that might detract from efforts to provide aid to all
in a timely manner (a tension experienced even if this
short-term loss is made up with longer-term benefits
regarding sustainability).
Ethical obligations can be mutually supportive, how-
ever. A commitment to engaging local communities in
planning and aid efforts, for example, helps identify and
minimize potential harms and unintended consequences
as well as promoting respect for cultural norms (Egeland
et al. 2011; Haver 2016; Hurst et al. 2009; Jaspars and
O'Callaghan 2010; Tribe et al. 2014). Appropriate
resource management strategies make it more likely that
organizations can meet their obligations to deliver the
highest possible quality of care (Banatvala and Zwi 2000;
Blair 1996; Leaning et al. 2011).
The precise ways in which ethical obligations are in
tension or are mutually supportive are context
dependent. Identifying and mapping these relationships
could help organizations manage ethical issues arising
during operations.
Humanitarian principles and challenges
Our review identified that the primary challenges to
neutrality were perceptions that humanitarian assistance
was innately political (Fouad et al. 2017; Geiger et al.
1989; Madhiwalla and Roy 2009) and that the very act of
working in conflict settings implied some type of
political affiliation (Rieffer-Flanagan 2009). Military and
political interventions operating under the guise of
humanitarian aid can lead combatants or beneficiaries to
doubt the neutrality of humanitarian organizations
(Asgary 2015; Clarinval and Biller-Andorno 2014; Cobey
et al. 1993; Duffield et al. 2012; Egeland et al. 2011;
Gastineau Campos and Farmer 2003). Perceptions of
non-neutrality can arise from using military escorts for
protection (Egeland et al. 2011; MacCormack 2007;
Poffley 2012; Slim 1995), the non-neutral conduct of
partners (Egeland et al. 2011; Haver 2016), or if combat-
ants insert themselves between humanitarian actors and
aid beneficiaries (Fegley 2009).
Maintaining neutrality can also be difficult for organi-
zations whose workers have experienced violence,
threats, or compulsion, or have borne witness to vio-
lence or advocated on behalf of victims of atrocities
(Blair 1996; Burkle Jr. et al. 2017; Civaner et al. 2017;
Farré 2013; Geiger et al. 1989; Slim 1997b).
Organizational members’own personal political views
could also affect perceptions of organizational neutrality
(Jones 2009). Humanitarian organizations operating in
resource scarce settings can also be perceived as lacking
neutrality because of how they allocate resources and
maintain secure access to those in need. Organizations
can inadvertently or unwittingly become affiliated with
other political objectives, for example, if they capitalize
upon access gained by other, partisan groups, or use
security services (e.g., formal military support) (Black
2003; Clarinval and Biller-Andorno 2014; Egeland et al.
2011; Gastineau Campos and Farmer 2003; Haver 2016;
Broussard et al. Journal of International Humanitarian Action (2019) 4:15 Page 9 of 13
Mačák 2014; Slim 1995; Sunga et al. 2006; Weiss 2016).
Additionally, working with local populations could be
seen as a tacit endorsement of an ideology or political
view (Joshi et al. 2008).
Organizational independence can be challenging to up-
hold. In complex emergencies with significant societal
breakdowns, unscrupulous actors may take advantage of
humanitarian organizations, restricting organizational
activities in ways that advance their own agendas (Burkle
Jr. et al. 2017; de Waal 2010). Unfortunately, when this
occurs, it can also create a proximity effect that casts
doubt upon the independence of other humanitarian
organizations (Civaner et al. 2017; Rieffer-Flanagan
2009; Slim 1995). Funding sources can compromise
independence by taking decision-making authority away
from organizations if funding is conditional, e.g., specify-
ing services offered or populations served (Clarinval and
Biller-Andorno 2014; Harding-Pink 2004; MacCormack
2007; Slim 1997b).
A key threat to impartiality arose from external pres-
sures to provide assistance not purely in accordance with
need. These pressures could include extortionary negoti-
ations demanding preferential treatment to gain access
for combatants (Fennell 1998) and criminalization of
providing aid to certain groups (Fouad et al. 2017).
When threats to impartiality result in aid given to com-
batants (e.g., when threats of violence force health care
workers to provide aid to combatants to prevent worse
harm to others), organizations and workers may believe
they are complicit in prolonging conflict (Fink 2007)
and/or have violated their duty to be impartial (Geiger
et al. 1989; Madhiwalla and Roy 2009). This can also
result in restricting programs to more secure areas
regardless of the needs of people living in insecure areas
(Haver 2016).
Societal breakdowns, the loss of normal order, and
punitive actions against humanitarian organizations se-
verely limit their ability to fulfill their duty of humanity
(Al-Moujahed et al. 2017; Fouad et al. 2017; Haver 2016;
Poffley 2012). Violent threats, abduction, torture, and
murder of humanitarian workers; blockade and theft of
materials and supplies; and the elimination of access to
or destruction of facilities also drastically impede hu-
manitarian missions (Alderslade 1995; Blair 1996; Cobey
et al. 1993; Fennell 1998; Fouad et al. 2017;Geiger et al.
1989; Haver 2016; Madhiwalla and Roy 2009; Redwood-
Campbell et al. 2014). Efforts to avoid violence, such as
concentrating operations in safe or comparatively secure
areas, preclude access or attention to the most vul-
nerable and in need (Haver 2016). Facilities in conflict
regions are often operating beyond their capacity and
providers are unable to meet demands in high-volume
crises or complex medical cases (Baskett 1994; Ben
Shahar 1993; Domres et al. 2012; Leaning et al. 2011).
Additionally, material scarcity and personnel shortages
contribute to organizations’limited efficacy of meeting
the needs of beneficiaries (Hunt 2008).
Threats to the emergent humanitarian principle of
solidarity were experienced in several ways. For example,
because solidarity implies both suffering with and
consulting community members, lack of coordination
between organizations could lead to disorder, duplicative
efforts, or blind spots in identifying community needs.
This in turn can undermine organizations’capacity for
solidarity (MacCormack 2007). In addition, humanitarian
workers themselves may struggle to feel they are in
solidarity with local populations. Barriers to recognizing
solidarity can also be exacerbated in violent situations and
other complex emergencies where extreme circumstances
can increase and reinforce humanitarian workers’percep-
tions of “otherness”(e.g., because of cultural and language
differences and/or economic disparities) of populations
being served (Hunt et al. 2014).
Implications of the relationship between ethical
obligations and humanitarian principles
Our review found multiple instances where ethical obli-
gations and humanitarian principles intersect (Tables 3
and 4). The implications of this intersection are twofold.
First, observing this connection brings additional clarity
to the nature of the challenges humanitarian organiza-
tions may face when operating in conflict settings. For
instance, seen through the intersection of ethics and hu-
manitarian principles, the obligation to involve local
communities in humanitarian response relates to funda-
mental ethical obligations of justice that involve fairness
in decision-making, may help facilitate respect for local
community norms, and could improve an organizations’
ability to deliver aid to communities in need, thereby
meeting humanitarian obligations of humanity. At the
same time, this must be done carefully, to preserve the
humanitarian commitment to independence.
Second, the intersection between ethics and humani-
tarianism in conflict settings creates the potential for
using ethical decision-making to support and improve
humanitarian action. Workshops were conducted with
Syrian humanitarian health workers in Gaziantep,
Turkey and Amman, Jordan to review an earlier version
of our literature review findings. Attendees supported
both our original decision to categorize humanitarian
principles and ethical obligations separately and the
potential for having a better understanding of their
intersection to improve organizational decision-making
around ethical challenges. Frameworks for ethical
decision-making have been proposed for humanitarian
settings (Clarinval and Biller-Andorno 2014; Hunt 2008).
These frameworks share a commitment to creating
decision processes that help identify the ethical issues at
Broussard et al. Journal of International Humanitarian Action (2019) 4:15 Page 10 of 13
stake in a particular situation and make better decisions
around them. However, the ethical issues at stake may not
always be clear to organizational stakeholders. Having in-
vestigated ethics obligations, humanitarian principles, and
their inter-relationships, our review should help organiza-
tions better operationalize existing frameworks as they
strive to maintain their ethical and humanitarian commit-
ments and make better decisions. Still, we must acknow-
ledge that whether these frameworks are both applicable
and feasible in conflict settings remains an open question
and should be the subject of future research.
Limitations
First, the search included only English language publica-
tions. Second, it is possible that not all the ethical and hu-
manitarian challenges organizations experience are
reported in the published literature. Third, our review did
not include gray literature such as reports from think
tanks, humanitarian organizations, and UN agencies,
raising the possibility the other obligations and challenges
have been identified. Fourth, we did not assess the quality
of included publications. Finally, as a qualitative study, our
findings involve subjectivity. It is possible that a different
research team would produce different findings or come to
different conclusions from these data. We believe that a
broad initial search strategy and a structured method of
qualitative content analysis helped address these
limitations.
Conclusion
Conflict settings present substantial barriers to humanitar-
ian health response efforts. By describing the range of
challenges humanitarian organizations have faced in ful-
filling their basic ethical obligations and humanitarian
principles, this review can increase awareness of the
nature and types of challenges organizations are likely to
experience while trying to uphold their commitments in
conflict settings. This can in turn aid organizational pre-
paredness, including stimulating efforts to train and moni-
tor humanitarian health workers and develop processes
for addressing challenges in the field. In addition, it lays
the foundation for future efforts aimed at tailoring existing
frameworks for ethical decision-making and evaluating
different methods of navigating these complex challenges.
Additional file
Additional file 1: Appendix 1. Full searches as executed in each of the
three databases (Ovid/EMBASE, Scopus, and PubMed) on May 17, 2017
(at 1:00, 1:08, and 1:15 PM EST, respectively). Appendix 2. References
used for codebook development. Appendix 3. Articles included in the
review (N=66). Appendix 4. Summary of main findings by organizational
ethics and humanitarian principle (N=number of articles where this code
was applied, and n=numbers of references where it was coded across
the N articles). (DOCX 54 kb)
Acknowledgements
The authors are grateful to Rachel Fabi, PhD, for earlier contributions to
the study.
Authors’contributions
GB made substantial contributions to the acquisition, analysis, and
interpretation of the data and the drafting of the manuscript. LR made
substantial contributions to the conception and design of the study; the
analysis and interpretation of the data; and revised the manuscript critically
for important intellectual content. CR made substantial contributions to the
conception and design of the study; the analysis and interpretation of the
data; and revised the manuscript critically for important intellectual content.
WM made substantial contributions to the interpretation of the data and
revised the manuscript critically for important intellectual content. SG made
substantial contributions to the acquisition of the data and revising the work
critically for important intellectual content. MD made substantial
contributions to the conception and design of the study; the analysis and
interpretation of the data; and the drafting of the manuscript. All authors
agree to be accountable for the accuracy and integrity of the work and gave
final approval of the manuscript.
Authors’information
The authors choose not to provide this information.
Funding
This research was funded by Elrha’s Research for Health in Humanitarian
Crises (R2HC) programme, funded equally by the Wellcome Trust and DFID,
with Elrha overseeing the programme’s execution and management. Its
contents are solely the responsibility of the authors and do not necessarily
represent the official views of Elrha or the r2hc. This funding source had no
role in the design of this study, the analysis or interpretation of data and
results, or the decision to write and submit the manuscript.
Availability of data and materials
The datasets used and/or analysed during the current study are available
from the corresponding author on reasonable request.
Competing interests
The authors declare that they have no competing interests.
Author details
1
Department of International Health, Johns Hopkins Bloomberg School of
Public Health, Baltimore, USA.
2
Center for Public Health and Human Rights,
Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.
3
Department of Epidemiology, Florida International University, Miami, USA.
4
Syrian American Medical Society, Washington DC, USA.
5
Department of
Chronic Disease Epidemiology, Yale School of Public Health, New Haven,
USA.
6
Berman Institute of Bioethics and Division of General Internal
Medicine, Johns Hopkins University, Baltimore, USA.
7
Current affiliation:
Center for Bioethics and Humanities and Division of General Internal
Medicine, University of Colorado, Mailstop B137, 13080 E. 19th Avenue,
Aurora, CO 80045, USA.
8
Berman Institute of Bioethics, Johns Hopkins
University, Baltimore, USA.
Received: 22 April 2019 Accepted: 12 August 2019
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