The invisibility of practical ethics has consequences; it reduces the capacity of the sector to absorb ethical guidance because it is foreign to its structures, leadership, and personnel (aside from some medical professionals and some other professional groups). The situation does, however, offer opportunities to reduce the likelihood of moral distress among humanitarian workers by making existing ethical guidelines more accessible, by improving the sector’s capacity for ethical reflection, and by providing practical guidance relevant to real-world ethical problems such as those typically encountered in infectious disease outbreaks.
We recommend the four following complementary approaches for the sector to address the ethical gap: 1) foster a culture of ethical deliberation and compromise, 2) provide institutional support to all staff including training specifically geared to the practical realities of an infectious disease outbreak, 3) use decision-making tools, and 4) support staff in moral distress.
Foster a culture of deliberation and compromise: process matters
Few ethical choices in outbreak response can be understood, or resolved, by reference to a universal equation or standard formula. Principles tend toward the high-level and the abstract and can, as Hugo Slim concludes, result in humanitarian workers feeling that “[they] always tell us what is good to do but they do not easily tell us what is best to do in difficult situations” [19 p. 44]. Conflict between principles and realities where all choices lead to some harm are inevitable [19] and practitioners need to understand this. Organisations should acknowledge that the application of principles to real world situations requires experience, self-reflection, and interpretation [19]. The misperception underlying much of the discourse on ethics is that deliberation should yield a triumphant claim (via reason, agreement, or authority) – a ‘right’ answer or way forward. Instead, deliberation should consider how the various options bring benefits and harms/costs and what, if any, compromise is possible [20]. This acknowledges the importance of the process by which decisions are made – and hence the imperative of procedural ethics [11, 21]. Procedural ethics aims to improve the quality and consistency of decisions, as well as reducing the distress and frustration of those affected by processes lacking ethical sensitivity.
Provide institutional ethics support and guidance
There is risk to staff who are not properly prepared and supported in their work. Both primary and vicarious trauma may cause significant distress. Organisational support is, therefore, not optional. Agencies have a duty of care to anticipate risks of moral distress, to establish a transparent feedback mechanism to understand staff experience of such risks, and to manage or mitigate against them. The principle of reciprocity, linked to fairness, increases the obligation to protect responders from harm because they accept heightened risks as part of their work. There are several actions and stances that the organisation can take to meet this obligation:
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Signal the importance of ethics by devoting resources to addressing the main ethical issues facing the organisation and its staff and articulating the organisation’s ethical and humanitarian principles. Ideally, training in ethics (and rational choice theory) would be integrated into humanitarian training more broadly.
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Demonstrate understanding of how positionality affects ethical considerations. Recognise and destabilise the overwhelming whiteness, and maleness, of the debate on humanitarian ethics and allow space for perspectives from the global south [22]. Address racism and sexism as ethical issues.
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Recruit the right people. Just as recruitment of staff should ensure the necessary professional competence, so it must seek those with experience and understanding of ethics and an appropriate personal profile for working in ethically compromising circumstances. In addition, staff who have experience working in infectious disease outbreaks are likely to have a better understanding of the associated risks, both to themselves and to affected populations, and may be better able to engage in suitably informed ethical decision-making.
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Prepare staff in advance for what they are likely to encounter. Support should begin at the pre-response stage, allowing staff to, “carefully consider whether they are prepared to deal with ethical issues that may lead to moral and psychological distress” [23]. International aid workers need a pre-departure briefing on expected conditions [24]. This should include discussion of their own beliefs, values, assumptions and biases, as well as relevant local beliefs and values [15].
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Shield frontline staff from having to make challenging individual or ad hoc decisions where these can be anticipated and preempted by action at a higher level: “[h] aving clear rules and guidelines for responders may decrease the moral stress that they take on individually” [25, p. 54]. Clear rules and priorities must also be set where there are differential policies for local or international staff, or between staff and patients [25, 26].
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Provide ethical clarity particularly for politically charged interventions (surveillance, coercive restrictions), circumstances characterised by abuse and violence by authorities, and services to marginalised communities such as ethnic minorities, indigenous communities, or displaced persons.
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Recognise and address vulnerabilities related to age, gender, and disability.
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Foster team support. Team support is critical to mental health generally and when dealing with moral distress in particular [27, 28]; in simple terms, talking to others helps. This should occur organically, and be supported by the agency (e.g. regular team debriefings to include ethical dilemmas), as should deliberate mentoring [15]. Research in healthcare settings shows that structured discussions of ethics can help distinguish between unavoidable harm and ethical failing [9]. It can, however, be challenging to make space for this in an emergency response, particularly in an outbreak setting in which infection prevention and control measures may complicate face-to-face interaction [29].
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Encourage personal responsibility and self-care. Agencies should foster a culture in which staff look after themselves [19]. Among the essential practical virtues for humanitarian workers are certain habits of self-care, the capacity to engage in meaningful self-reflection and the willingness to interrogate their own values.
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Use scenario or case-based training, particularly that which is informed by local knowledge [16, 23]. Evidence suggests that amongst frontline humanitarian staff case-based training is more effective than abstract ethics lectures [15]. Scenario-based training, particularly that which is informed by local knowledge and contextualised through community involvement, also reinforces the need to seek support for ethical issues and overcome them as a team [15].
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Document and share ethically challenging cases and promote institutional memory to assist when similar situations occur again [17].
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Engage expert support on ethics to assist when necessary [13].
Use decision-making tools and frameworks
Frameworks or tools exist to help navigate ethical problems. The ethics literature consistently refers to principles of decision-making procedure that draw upon the work of Daniels and others [11, 21, 30]. This framework includes five key values: accountability, inclusiveness, openness and transparency, reasonableness, and reviewability. The Humanitarian Health Ethics research group has produced a six-step tool [20] that helps identify ethical issues and the related costs and benefits of options. Whilst generally seen as helpful in tests, it raised concerns about the requirement for time or prior familiarity [9]. A second framework was produced by Clarinval and Biller-Adorno, and involves a similar, though arguably more challenging, process [13]. These tools translate operational or programmatic dilemmas/challenges into the language of ethics, helping to clarify what is at stake. They also bring structure and consistency to decisions [31]. Ultimately, tools and guidelines need to be immediately relevant to be useful; hence, tools and guidelines which speak directly to the types of challenges inherent in infectious disease outbreaks are needed. Furthermore, there is a need to evaluate and improve the utility of exiting frameworks and tools.
Support staff in moral distress
Moral distress can be precipitated by individual, institutional, and broader external factors and has consequences for the psychological, emotional, and physical health of staff, and for the care they deliver [32, 33]. The need to address moral distress is both a duty (insofar as it fulfils basic obligations of organisations to provide for the occupational health of their staff) and highly pragmatic. Just as with health or security risks, “certain issues faced by humanitarian aid workers are ethical issues, not geopolitical or managerial questions, and humanitarian actors are therefore likely to face ethical dilemmas that lead to moral distress” [13, p. 5]. Moral distress forms part of a humanitarian’s moral experience, even if not all moral distress is the direct result of ethical tension or ethical lapses. This experience exceeds the rational or deliberative processing of ethical tensions, as it is rooted in individual psychology rather than within a particular context [29]. Dealing with moral distress forms part of a wider organisational duty to support the overall mental health and well-being of humanitarian aid workers [9].