|Original Concepts and Ideas Taken From Articles||Cross-cutting Themes||Tensions and Future Research||Major Theme|
Lacking or dysfunctional review boards in LMICs |
Inability of traditional ethics review during an emergency [22, 23]
Real time responsiveness (RTR) ethical review 
Ethical review challenges in humanitarian setting 
Challenge of timely, efficient and comprehensive ethical review [11, 26]
Traditional ethics review is not suitable to practical realties [27, 28]
MSFs ERB during Ebola outbreak [29, 30]
Ethics review board specific for MSF 
Recommendations for improving ethical review 
Unique set of ethical priorities governing post-disaster research [33, 34]
Ethical guidelines revealed two core themes: vulnerability and review process 
Deviation from normal ethical oversight in disaster setting may be acceptable 
Historical lack of oversight in humanitarian contexts 
Uniqueness of ethical review during Ebola outbreak 
Regional collaboration for ethical review [39, 40]
In-country, local review [21, 30]|
Timely ethics review during and emergency [11, 22, 23, 29, 31, 35, 38]
Question as to whether or not ethics review in the humanitarian setting should have different standards compared with traditional review [27, 28, 31, 33, 35, 36, 38]
Collaboration across institutions for ethical review [37, 39]
Inherent vulnerability makes ethical review processes extremely important. However, the timely nature of humanitarian situations makes traditional ethics review impractical.
Outline the specifics of ethical review of research in the humanitarian setting, as this process should be unique from traditional ethics review.
Ensuring that communities enjoy maximum benefit of research |
Case studies on ethical research 
Engagement with local governments/health authorities 
“Uncomfortable power dynamic” between researchers and communities 
Low research output from researchers from LMIC 
Community engagement to facilitate a clinical trial 
Ethical entry” and compliance with local cultural norms 
Utilizing gatekeepers may augment hierarchies of power 
Thai Government as a gatekeeper via a permit system 
Community involvement as benchmark for ethical research [48, 49]
Risk of cooperating with nefarious authorities 
Ambivalence about working with authority figures 
Local stakeholders involvement in ethicial review 
Ethics committee members view of community engagement 
Community engagement to avoid “clinical trial exploitation” 
Will local populations benefit from the research? [21, 30, 41, 42, 46, 48]|
Community engagement enhances cultural understanding, which can help reduce harm amongst participants [22, 43, 44, 46, 48]
Engagement with local authorities may be necessary, though it has potential unintended consequences on local power dynamics and perceived legitimacy of the researchers [47, 50]
Limited capacity of locals to conduct their own research [21, 33, 45, 47, 49]
There is a need to work with local authorities for both practical and ethical reasons, though there is concern that this cooperation can be seen as legitimizing this authority. This may be undesirable.
Without local participation it is unlikely that they will reap the full benefits of the research product. However, including locals in research is inherently difficult.
Formal post hoc evaluations to help determine if the community did, in fact, benefit from the research product.
Strategies to prepare locals for a participatory role in research are needed.
Argument for single arm design over RCT for Ebola clinical trials |
Clinical equipoise as justification for Ebola Virus Disease RTCs 
Clinical equipoise justifies research in the humanitarian setting 
Proposal for adaptive (Bayesian, cluster or step wedge) research 
An a priori exclusion of pregnant subjects would deprive them of potential benefits of the research 
Community engagement to avoid “clinical trial exploitation” 
The individual vs. the collective interest complicates clinical trial ethics 
Lack of focus on positive obligations of researchers toward participants 
Systematic review demonstrates deviation from normal ethical oversight during clinical trials 
Study design has ethical implications [38, 55]
Refutation of a priori right to unvalidated clinical interventions 
Clinical trials where there is no known treatment for a catastrophic disease [27, 29, 30, 46, 51, 52]|
Oversight might be necessary to avoid exploitation [30, 36]
Clinical equipoise and justification of RCTs [38, 54, 56]
It is unclear which type of clinical trial is most appropriate in the humanitarian setting.
Review or meta-analysis to evaluate the best methodology for clinical trials in the humanitarian setting.
Collaboration between academics and practitioners |
Conflict in between researcher’s objectivity, and humanitarian’s advocacy 
Researchers simultaneously participating in relief efforts 
Research should be both academically sound and action driven [11, 59]
Research is justified insofar as it is not compromising relief efforts 
MSF’s refusal to participate in research on treatment rationing 
The evolution form pure researcher to researcher-practitioner 
Justification for research in conflict setting 
Explanation of MSFs ethics of studying HIV medication rationing 
Generally limited resources in these settings 
Effective research design might inhibit optimal treatment initiatives 
Research at the expense of intervention, as these two goals may come in conflict [53, 57, 58, 60, 62, 64]|
Collaboration between NGOs and academic institutions [41, 59, 61]
Discussions on the ethics of researching policies, which may be in conflict with humanitarian principles [55, 63]
Research should be both academically rigorous and practical.
Given that humanitarian response is grounded in specific principles is it ethical to research policies that fall outside of these principles?
Strengthen the relationships between humanitarian aid groups and academic institutions.
Reassessing a participant’s consent during the experiment |
Informed consent in the setting of a particularly fatal disease 
Use of a “gatekeeper” when seeking informed consent 
A more nuanced view of consent might be more suitable for emergencies 
More flexible approach to consent 
“Humanitarian misconception” 
Challenges of consenting children 
Consent during disasters may be coercive 
Exclusion of groups may undermined justice 
Regional collaboration for ethical review 
Dynamic consent [38, 44]|
Participants may find it difficult to separate consent for research from receiving aid [27, 38, 46]
Use of gatekeepers for attaining consent 
Acceptance of less rigid consent procedures in the humanitarian setting [21, 22]
Forcing participants to relive trauma for the purpose of research raises ethical questions [44, 65]
Unavoidable coercion 
May be necessary, for both practical and cultural reasons, to obtain consent for participation through an intermediary, which is in conflict with principle of autonomy.
Outline the specifics of consent for participation in research in the humanitarian setting.
Child participation in conflict with local norms |
Use of gatekeepers for informed consent 
Research teams with local knowledge [50, 57]
Thai permit system vs. western funding regulations 
Research teams with local knowledge 
Cultural relativism |
Gatekeepers and cultural liaisons [21, 47]
Cultural competency and humility [50, 57]
Much of the literature puts a premium on respecting cultural norms. There is also an understanding that these norms may be in conflict with accepted ethical principles.
Identify core principles or universal research ethics, which supersede cultural norms in so far as these norms come in conflict with the former, and thus justify their disregard.
Discussing sensitive topics can put researchers at risk |
Unethical to put a researcher in a dangerous position without clear adequate forethought [68, 69]
Researchers may witness horrific events, and should consent to these risks [23, 49]
Need for formal protocols for responding to threatening situations [21, 68]|
Concent of researcher [23, 49]
Working in humanitarian contexts comes with risk, and minimizing this risk is an ethical imperative.
Formal protocols for minimizing the risk to researchers.
|Risks to Researchers|
Consensus that children should be involved as research participants |
Researchers must anticipate urgent issues [43, 70]
Consenting children to relive trauma for the purpose of research 
Fundamental right that children be allowed to participate in research [43, 67, 70]|
Challenges of consenting children [65, 70]
Children are particularly vulnerable but systematically excluding them from research participation could be unethical.
Clear guidelines for determining when the risks of including children outweigh the benefits.
Concern around the extraction of knowledge from disaster stricken areas |
Data sharing as ethical imperative 
|Data ownership as it relates to who benefits from research [45, 57]||
Potential extractive relationship in which the data produced in low-income countries is circulated only in high-income countries.
Standardized policies for data ownership
Stigmatization makes conducting research on mental health in LMICs particularly difficult |
Friction between procedural ethics and ethics in practice vis-à-vis mental health 
|Local stigma towards mental health complicates research on these topics [21, 22]||
Given pervasive stigma, studying mental health might put the subjects as well as researchers at risk.
Develop strategies to dispel stigma and misconceptions about mental health.