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  • Preparing humanitarians to address ethical problems

    McGowan, CR; Baxter, L; DuBois, M; Sheather, J; Khondaker, R; Cummings, R; Watkins, K (BMC, 2020-11-04)
    Infectious disease outbreaks represent potentially catastrophic threats to those affected by humanitarian crises. High transmissibility, crowded living conditions, widespread co-morbidities, and a lack of intensive care capacity may amplify the effects of the outbreak on already vulnerable populations and present humanitarian actors with intense ethical problems. We argue that there are significant and troubling gaps in ethical awareness at the level of humanitarian praxis. Though some ethical guidance does exist most of it is directed at public health experts and fails to speak to the day-to-day ethical challenges confronted by frontline humanitarians. In responding to infectious disease outbreaks humanitarian workers are likely to grapple with complex dilemmas opening the door to moral distress and burnout.
  • A reflection on case reporting in resource-limited settings

    Wind, A (Oxford University Press (OUP), 2019-12-09)
    In 2015, I was in the Democratic Republic of the Congo (DRC), working as a pediatrician with Médecins Sans Frontières (MSF). As had been the case in my two previous assignments with MSF, I encountered many interesting and challenging cases—cases that I had never experienced prior to working in resource limited settings. Contrary to when I work in the USA and have access to extensive laboratory exams and diagnostic testing, in our hospital in the DRC, no such tools were available, and thus I needed to use a whole new level of clinical skills and deductive reasoning. To make clinical management even more challenging, I rarely saw these types of cases written about or published in the medical literature. I was discouraged that although these clinical examples were perfect fodder for medical case discussions, they did not have the ‘components’ required for a traditional case report. In frustration, I wrote the following: ‘The reason why we, those working in “resource limited settings”, do not often attempt to publish case reports is because we don’t often find an answer. We think that published articles and case reports should be neat and clean. That students or colleagues should be able to read a mystery case, try to solve the puzzle, and at the end be rewarded with an answer brought about by some obscure lab or radiology report. But that’s not what happens. The world of medicine in resource limited settings isn’t neat and clean. It’s frustrating and messy. Mystifying and sad. You can come up with a million differentials but ultimately the child, because of, or in despite of, your chosen treatment, makes it. Or doesn’t make it. And you never get an answer. You don’t learn. And you can try to look in the literature, but the research will talk about IGF1 and MRI and calcium. I can’t even get a And so, the mystery disease leads to a mystery death and you are left feeling powerless. And there is not even a take home message.’ I am excited that now with the Oxford Medical Case Reports collaboration, there is a platform to start regaining some power, to start creating a take-home message. There is a platform for collaboration amongst all of us medical professionals working in resource limited settings—a platform to share these unique cases to perhaps discover that they are not so unique at all. They are just not published.
  • Care in crises: Nursing and humanitarian aid

    Freeman, A (Lippincott Williams & Wilkins, 2018-07)
  • 'He who helps the guilty, shares the crime'? INGOs, moral narcissism and complicity in wrongdoing

    Buth, P; de Gryse, B; Healy, S; Hoedt, V; Newell, T; Pintaldi, G; Del Valle, H; Sheather, JC; Wong, S (BMJ Publishing Group, 2018-03-17)
    Humanitarian organisations often work alongside those responsible for serious wrongdoing. In these circumstances, accusations of moral complicity are sometimes levelled at decision makers. These accusations can carry a strong if unfocused moral charge and are frequently the source of significant moral unease. In this paper, we explore the meaning and usefulness of complicity and its relation to moral accountability. We also examine the impact of concerns about complicity on the motivation of humanitarian staff and the risk that complicity may lead to a retreat into moral narcissism. Moral narcissism is the possibility that where humanitarian actors inadvertently become implicated in wrongdoing, they may focus more on their image as self-consciously good actors than on the interests of potential beneficiaries. Moral narcissism can be triggered where accusations of complicity are made and can slew decision making. We look at three interventions by Médecins Sans Frontières that gave rise to questions of complicity. We question its decision-guiding usefulness. Drawing on recent thought, we suggest that complicity can helpfully draw attention to the presence of moral conflict and to the way International Non-Governmental Organisations (INGOs) can be drawn into unintentional wrongdoing. We acknowledge the moral challenge that complicity presents to humanitarian staff but argue that complicity does not help INGOs make tough decisions in morally compromising situations as to whether they should continue with an intervention or pull out.
  • Tuberculosis, human rights and ethics.

    Varaine, F (International Union Against Tuberculosis and Lung Disease, 2017-10-01)
  • A Médecins Sans Frontières Ethics Framework for Humanitarian Innovation

    Sheather, J; Jobanputra, K; Schopper, D; Pringle, J; Venis, S; Wong, S; Vincent-Smith, R (Public Library of Medicine (PLoS), 2016-09-06)
    Kiran Jobanputra and colleagues describe an ethics framework to support the ethics oversight of innovation projects in medical humanitarian contexts.
  • The Ebola Clinical Trials: a Precedent for Research Ethics in Disasters

    Calain, P (BMJ Publishing Group, 2016-08-29)
    The West African Ebola epidemic has set in motion a collective endeavour to conduct accelerated clinical trials, testing unproven but potentially lifesaving interventions in the course of a major public health crisis. This unprecedented effort was supported by the recommendations of an ad hoc ethics panel convened in August 2014 by the WHO. By considering why and on what conditions the exceptional circumstances of the Ebola epidemic justified the use of unproven interventions, the panel's recommendations have challenged conventional thinking about therapeutic development and clinical research ethics. At the same time, unanswered ethical questions have emerged, in particular: (i) the specification of exceptional circumstances, (ii) the specification of unproven interventions, (iii) the goals of interventional research in terms of individual versus collective interests, (iv) the place of adaptive trial designs and (v) the exact meaning of compassionate use with unapproved interventions. Examination of these questions, in parallel with empirical data from research sites, will help build pragmatic foundations for disaster research ethics. Furthermore, the Ebola clinical trials signal an evolution in the current paradigms of therapeutic research, beyond the case of epidemic emergencies.
  • Why ethics is indispensable for good-quality operational research [Short communication]

    Edginton, M; Enarson, D; Zachariah, R; Reid, T; Satyanarayana, S; Bissell, K; Hinderaker, S G; Harries, A D (The TB Union, 2012-03)
  • Ethical dilemmas in medical humanitarian practice: cases for reflection from Médecins Sans Frontières.

    Sheather, J; Shah, T; British Medical Association, Ethics Department, BMA House, London, UK. (2011-03)
    Médecins Sans Frontières (MSF) is an independent medical humanitarian organisation working in over 70 countries. It has provided medical assistance for over 35 years to populations vulnerable through conflict, disease and inadequate health systems. Medical ethics define the starting point of the relationship between medical staff and patients. The ethics of humanitarian interventions and of research in conflict settings are much debated. However, less is known about the ethical dilemmas faced by medical humanitarian staff in their daily work. Ethical dilemmas can be intensified in humanitarian contexts by insecure environments, lack of optimum care, language barriers, potentially heightened power discrepancies between care providers and patients, differing cultural values and perceptions of patients, communities and medical staff. Time constraints, stressful conditions and lack of familiarity with ethical frameworks can prevent reflection on these dilemmas, as can frustration that such reflection does not necessarily provide instant solutions. Lack of reflection, however, can be distressing for medical practitioners and can reduce the quality of care. Ethical reflection has a central role in MSF, and the organisation uses ethical frameworks to help with clinical and programmatic decisions as well as in deliberations over operational research. We illustrate and discuss some real ethical dilemmas facing MSF teams. Only by sharing and seeking guidance can MSF and similar actors make more thoughtful and appropriate decisions. Our aim in sharing these cases is to invite discussion and dialogue in the wider medical community working in crisis, conflict or with severe resource limitations.
  • Research Ethics and International Epidemic Response: The Case of Ebola and Marburg Hemmorrhagic Fevers

    Calain, P; Fiore, N; Poncin, M; Hurst, S; Medecins Sans Frontieres (Oxford University Press, 2009-08-01)
    Outbreaks of filovirus (Ebola and Marburg) hemorrhagic fevers in Africa are typically the theater of rescue activities involving international experts and agencies tasked with reinforcing national authorities in clinical management, biological diagnosis, sanitation, public health surveillance and coordination. These outbreaks can be seen to be as a paradigm for ethical issues posed by by epidemic emergencies, through the convergence of such themes as: isolation and quarantine, privacy and confidentiality and the interpretation of ethical norms across different ethnocultural settings. With an emphasis on the boundaries between public health investigations and research, this article reviews specific challenges, past practices and current normative documents relevant to the application of ethical standards in the course of outbreaks of filovirus hemorrhagic fevers. Aside from the commonly identified issues of informed consent, and institutional review process, we argue for more clarify over the specification of which communities are expected to share benefits, and we advocate for the use of collective definitions of duty to care and standard of care. We propose new elaborations around existing normative instruments, and we suggest some pathways toward more comprehensive approaches to the ethics of research in outbreak situations.
  • Research ethics review in humanitarian contexts: the experience of the independent ethics review board of Médecins Sans Frontières.

    Schopper, D; Upshur, R; Matthys, F; Singh, J; Bandewar, S S; Ahmad, A; van Dongen, E; Ethics Review Board, Médecins Sans Frontières, Geneva, Switzerland. (2009-07-15)
  • Ethics of conducting research in conflict settings.

    Ford, N; Mills, E J; Zachariah, R; Upshur, R (2009-07-10)
    ABSTRACT: Humanitarian agencies are increasingly engaged in research in conflict and post-conflict settings. This is justified by the need to improve the quality of assistance provided in these settings and to collect evidence of the highest standard to inform advocacy and policy change. The instability of conflict-affected areas, and the heightened vulnerability of populations caught in conflict, calls for careful consideration of the research methods employed, the levels of evidence sought, and ethical requirements. Special attention needs to be placed on the feasibility and necessity of doing research in conflict-settings, and the harm-benefit ratio for potential research participants.