Humanitarian intervention: what are the ethical challenges facing aid workers, and how should they be addressed?

Dr. Ramin Asgary, M.D., M.P.H.
Ramin Asgary, M.D., M.P.H.

By: Elizabeth Yuko, Ph.D.

Recent natural disasters such as Hurricane Katrina, the earthquake in Haiti, and the tsunami in Southeast Asia and the Arab Spring resulted in an increase in short-term medical volunteerism. This type of medical practice raises many ethical issues for both the medical practitioners and their institutions. Dr. Ramin Asgary, Assistant Professor in New York University’s Department of Medicine, has experienced these ethical issues from two perspectives: as a physician working abroad in humanitarian settings, and as an academic examining the ethics of short-term medical volunteerism, and aid workers in general. Dr. Asgary began international aid work in 1997 with Médecins Sans Frontières/Doctors Without Borders, working in mostly high-security war-torn areas with displaced populations such as Afghan refugees, and locations such as the breakaway state of Abkhazia, Darfur, and the Somalia/Kenya borders, among other places. He has also worked with other international non-governmental humanitarian organizations in Haiti, Ethiopia, Madagascar, and Liberia in post-natural-disaster, poor and rural areas. “My experience was moving, life changing, and tough at times,” Dr. Asgary said. “It’s generally a very physically and emotionally demanding work, but rewarding. I felt I tried to ignore self-care and just try to plow through works which were unending.” Dr. Asgary described encountering issues with medical ethics, population and public health ethics, and humanitarian and sociopolitical ethics, including: “rationing medical care because of limited resources; the inability to address tremendous needs while they understand that almost all are treatable easily in other developed settings; dealing with feelings of frustration and helplessness; dealing with leaving places they work (that is the hardest) and then reintegration (very difficult); feelings of guilt; anger towards an ignorant society; problems digesting political directions in aid, not a need-based approach; community consent and patient autonomy choices; low-quality aid work; significant social inequalities and political forces that are the fundamental cause of the conflict or humanitarian situation and are not address; being frustrated with ‘Band-aid’ work; and abuse of humanitarian space by military humanitarian actions in recent years such as in Afghanistan, Iraq, and Arab uprising.” Dr. Asgary first decided to write about these medical ethics issues from an academic perspective in 2008-2009, following his work on the Darfur and Somalia/Kenya border: “The tipping point for me was I felt compelled to write and investigate it systematically and the fact that much less than I expected was researched on these or communicated – almost nothing.” Why has there been so little research conducted on the ethical experiences and perspectives of aid workers and physicians working abroad? Dr. Asgary thinks it is because the people who experience this type of work do not have the time or energy to write about it and don’t see it as a priority. “You end up working and working and bond with like-minded people with the same experience. Though I think people have written about their experience, but not in systematic ways or in the mainstream medical journals,” Dr. Asgary said. “Ethics by itself is a heavy topic and takes an emotional toll and energy. It’s not easy to write about.” Furthermore, Dr. Asgary indicated that there has not been a lot written on the ethics of aid workers because “everything is so focused, rightfully, on aid itself and beneficiaries.” In a 2013 article in the Journal of Medical Ethics, Dr. Asgary recommended creating standardized ethical guidelines for aid workers. At this stage, he is unsure if any systematic progress has been made, or guidelines created, though he believes that generally, more attention has been devoted to the subject in recent years.  Dr. Asgary also explained that that article took two years to write and publish because the reviewers were so unfamiliar with the topic area and terrain. His final version, he believes, is toned down (“for the better, though!”). “I felt I was trying to teach them extensively at first and give the very basic I ignorantly expected they know,” he said. “It was a lesson for me to know how unfamiliar we are when it comes to the context of and ethics in the humanitarian world.” Moreover, cultural relativism plays a large role in training aid workers, as they are not only working in a foreign country with different customs and values, but also in the context of working with other aid workers from different countries. Dr. Asgary explained: “Moral values, rights values, cultures, and sociopolitical context where aid workers come from play huge roles in the experience of both themselves and beneficiaries. Aid workers in the very same program may have completely different backgrounds and expectations and values.” In addition to working abroad, Dr. Asgary has also worked extensively with refugees and asylum seekers in the United States over the last 14 years, which he described as being “emotionally challenging,” and which prompted him to think more about the ethics of working with vulnerable populations. Many thanks to Dr. Ramin Asgary for his participation and expertise.  For more information, please see, for example: Asgary, R., & Junck, E. (2013). New trends of short-term humanitarian medical volunteerism: professional and ethical considerations. Journal of Medical Ethics39(10), 625-631. Asgary, R., & Smith, C. L. (2013). Ethical and professional considerations providing medical evaluation and care to refugee asylum seekers. The American Journal of Bioethics13(7), 3-12. Asgary, R. (2013, November). Ethical experiences and dilemmas of career medical aid workers; Characteristics and determinants. In 141st APHA Annual Meeting (November 2-November 6, 2013). APHA.


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