DIFFICULT DECISION-MAKING, COMPROMISE, AND MORAL DISTRESS IN MEDICAL HUMANITARIAN RESPONSE

James Smith

Introduction

Humanitarian actors are often faced with multiple and repeated pressures in challenging and dynamic contexts. The practice of humanitarian medicine in such situations regularly demands that staff make difficult decisions, which in turn can have significant ethical implications. In 'Compromised Humanitarianism' Cullity (2010: 155) draws on the same fundamental premise to ask, 'how can humanitarianism operate in such conditions [as it characteristically must] without itself becoming morally compromised?'

For an organisation like Médecins Sans Frontières/Doctors Without Borders (MSF), which actively 'rejects the idea that poor people deserve third-rate medical care and [in turn] strives to provide high-quality care to patients' (MSF, n.d.) making concessions during the implementation of programmes can be the source of profound moral discomfort.

As a partial response to the difficulties inherent in humanitarian decision-making, and in recognition of inconsistencies in the outcome of such processes over time and in different contexts, a growing body of scholarship has sought to explore the political and procedural factors that shape decision-making in humanitarian programmes (Fuller, 2012; Le Pape, 2011: 248; Michael & Zwi, 2002). This pursuit is perceived as a desire to better make, justify, and defend choices, and to minimise moral discomfort. Such efforts are further bolstered by repeated sector-wide calls for greater accountability and transparency in the development and implementation of humanitarian programmes (Clarinval & Biller-Andorno, 2014).

While it is widely recognised that a degree of compromise is inevitable in humanitarian decision-making, and the broader practice of medical humanitarianism, the development of ethically informed and experientially derived frameworks with which to approach such issues is as of yet incomplete. In recognition of the humanitarian's position as 'moral entrepreneur' (Brauman, 2012: 20), this paper draws from selected peer-reviewed publications, reports and presentations to situate current debates pertaining to humanitarian decision-making, compromise, and moral distress in medical humanitarian response.

The Humanitarian Predicament

The practice of humanitarian medicine is broadly characterised by the provision of immediate, yet often prolonged, assistance to crisis-affected populations. Given the scale, scope and dynamism of needs in such situations and the finite resources available to humanitarian organisations, staff are regularly pressed to make decisions related to both the allocation of resources at the project level, and the distribution of their programme of activities within a much broader national, regional and global spatial frame (Hunt, 2008; Calain & Schwartz, 2014). Additional contextual constraints such as suboptimal access, insecurity, and inadequate supporting infrastructure, and internal constraints such as shifting intra-organisational priorities, further complicate the ability to deliver medical humanitarian assistance.

Over the course of the last 45 years, Médecins Sans Frontières/ Doctors Without Borders (MSF) has provided 'emergency aid to people affected by armed conflict, epidemics, natural disasters and exclusion from healthcare' (MSF, ND). Following MSF's receipt of the Nobel Peace Prize in 1999, then MSF International President James Orbinski acknowledged the humanitarian's responsibility to respond 'wherever in the world there is manifest distress'. This core commitment is central to MSF's Charter, and is often recited as a constitutive component of the humanitarian identity.

However, irrespective of the strength of the commitment to alleviating suffering, the impetus to assist populations in need is rarely commensurate with the financial, human, and other material resources available to fully realise this commitment in any given context (Michael & Zwi, 2002). As such, with very few exceptions difficult decision-making has become a defining feature of medical humanitarian response. De Waal captures this sentiment in his own analysis of 'humanitarian's tragedies', when he describes the context in which humanitarianism is practised as 'a world in which human ideals fail to match the realities of the human condition' (2010: 130). Utilising a term first coined by Calabresi and Bobbitt, Heyse argues that the same discrepancy between the number of crisis-affected people worldwide, and the finite means with which to respond to their resultant needs, prompts humanitarian organisations to make 'tragic choices' (2013: 69–70).

In this respect, we can speak of the inevitability – though not necessarily an acceptance – of difficult decision-making, which in turn necessitates an exploration of the terms on which compromise is negotiated, and of its impact on those who are compromised. Such work inevitably derives from a growing body of research related to choices and decision-making (Fuller, 2006; Heyse, 2013), quality and standards of care (Brauman & Beck, 2017), and the principles and motivations that underpin medical humanitarian response (Rességuier, 2017; see Komenská, this volume).

The issue of compromise at the macro level – often reported in relation to access and negotiation, and the withdrawal of humanitarian activities – has been expounded elsewhere, and establishes an additional layer of complexity that cannot be overlooked in any comprehensive exploration of decision-making and compromise at the interpersonal – or micro – level. Nevertheless, authors have dedicated much effort to outlining such issues in other fora, and for the purpose of this paper, while reference is made in passing to macro-level issues, I simply signpost here some seminal comprehensive and empirically informed contributions (Rieff, 2002; Terry, 2002; Magone, Neuman & Weissman, 2012).

Multi-tiered Ethical Challenges

Existing research related to ethical issues in decision-making in humanitarian response can be broadly divided into three categories. The first encompasses literature that explores meta-level organisational decision-making processes (Heyse, 2013), with a focus on key themes such as priority-setting (Fuller, 2012), justice (Rubenstein, 2009), the fair distribution of resources (Hurst, Mezger & Mauron, 2009), legitimacy (Calain, 2012), accountability (Hilhorst, 2002), and solidarity (Tiller, 2016). At the meta-level, these questions are concerned with the decision to intervene in a given context, with subsequent attention paid to the consequence of such actions, and the opportunity cost of intervention. Related scholarly work has interrogated the accuracy and conduct of needs assessments (Bradbury et al., 2003; Darcy & Hofmann, 2003; de Geoffroy & Grunewald, 2008) and the decision to withdraw assistance (Abramowitz, 2016; see Hunt & Miao, this volume).

Decisions at both the meta (identity) and macro levels account for a multitude of competing priorities, against which the consequent composition of medical assistance can be determined. However, at the micro level – in this case, the level of the clinical encounter – meta- and macro-level decisions become less immediately relevant, as individual healthcare providers are faced with the challenge of delivering medical care to individual patients (see Figure 1.1). As such, a second category of research has emerged; qualitative studies have attempted to profile the challenges faced by staff in the delivery of medical humanitarian assistance, and have identified a number of key themes, along with possible solutions that may protect against 'moral distress' (Jameton, 1984), or assist in the dissipation of 'moral residue' (Webster & Baylis, 2000) (see Table 1.1).

Ethics at the Level of the Clinical Encounter

Hunt and colleagues have defined two recurrent features identifiable in many humanitarian crises in low-resource contexts: contextual insufficiency, which is to say a lack of the required personnel, material and financial resources, and infrastructure required to meet the needs of the local population; and dramatically increased population needs (Hunt et al., 2014). The so-called moral landscape of humanitarian response is further shaped by: cultural and power differences between staff and the local population, and within teams; organisational work practices that promote a culture of self-sacrifice in the face of overwhelming needs; and minimal regulatory oversight and a lack of clear guidance (Hunt, 2011). Given the imbalance between needs and means, humanitarians are pressed to practice a multidimensional 'ethics of insufficiency' of sorts, as they recalibrate their practice within a diversity of complex contexts. The aforementioned themes can thus be loosely categorised as follows:

Action Beyond Capacity: Humanitarian healthcare providers are regularly pressed to engage in the distribution of scarce resources. This is further exacerbated by often extensive population needs, for which medical activities constitute only a partial response. Capacity can be further constrained not only by contextual pressures, but by organisational decisions related to the staffing of programmes, and whether or not to invest in particular activities (Schwartz et al., 2010). This is pertinent in the case of vertical programmes that are artificially limited in scope (Devakumar, 2010), and emergency programmes that are similarly limited in scope, often as a result of logistical, security, and other barriers. In such circumstances, healthcare providers may be pressed to practice a form of triage, the terms for which may not be universally accepted by all members of a team. Important here is the way in which 'capacity' is interpreted by healthcare providers, and of the ways in which capacity and scarcity may be negotiated and disputed both between and within teams.

Action Beyond Culture: International humanitarian workers are transposed from often dramatically different healthcare environments, frequently without a strong prior appreciation of cultural differences or of variation in the socio-cultural dynamics of health, illness, death, and dying. As Hunt states, 'the moral dimension of humanitarian work is rendered more complex by the international and transcultural nature of this work' (2011: 606). If poorly understood and actioned, cultural dynamics can cause problems, particularly in relation to hierarchies of power and intra-team relations (Schwartz et al., 2010). Unsurprising is reference to cultural relativism in the available qualitative literature (ibid.). Importantly, cultural factors are shaped by individual subjectivities; existing research has focused predominantly on the experience of North American and European staff, whose sociocultural experience may differ from that of colleagues who have lived, worked, and developed their professional expertise elsewhere.

Action Beyond Competence: Given the scale and scope of humanitarian needs, it is not uncommon for humanitarian healthcare providers to be pressed to make, and act on, decisions beyond their level of competence (Hunt, Schwartz & Fraser, 2013). Such is the often unexpected and rapidly changing nature of humanitarian crises. This is further problematised by a lack of clear regulatory oversight, and an absence of clear systems and processes for accountability (Hunt, 2011).

Acting Beyond Context: Humanitarian crises have a tendency to exist in close relation with existing or historic social and political systems and structures that perpetuate injustice, violence, and exploitation. Humanitarian healthcare providers may recognise the complex underlying causes of a humanitarian crisis, while constrained by the inherent limits of humanitarian response. This may pose an additional challenge for healthcare providers who must attempt to operate within the space afforded to medical humanitarian action in such settings.

Aspects of public health ethics are clearly identifiable in each of the above categories. To some humanitarian workers the challenge arguably only partially reconcilable – manifests as a need to achieve some form of equilibrium between the rule of rescue, and the inevitable focus on aggregate populations and interventions that seek to best distribute medical assistance. Value pluralism, and the subjective weight afforded to individual values, principles, professional and organisational codes of practice, legal frameworks, and so on, naturally present a major challenge for humanitarian healthcare providers. These values and principles together comprise an ethical matrix of sorts, which is likely to be interpreted and actioned in a diversity of different ways dependent on the personal and professional experience of individual healthcare providers.

Exploring Difficult Choices and Moral Dilemmas

The plurality of principles and values available by which to guide isolated and cumulative actions can cause distress, particularly when such values appear to contradict one another (Fuller, 2003; Gotowiec & Cantor-Graae, 2017). MSF staff are continually reminded that 'the individual medical-humanitarian act ... is central to the work of MSF' (Le Pape, 2011). However, if this were truly the case, medical assistance would adopt an expansive characteristic, continually shifting and adapting to meet the needs of patients in an ever-increasing number of contexts worldwide.

Achieving 'health', as defined by the World Health Organization (ND), is an iterative process that is difficult to fully realise, even with the support of the most optimally resourced of health systems. As medical technologies and new forms of treatment emerge, health professionals are further pressed to adapt their practice in pursuit of the most effective treatment for their patients. If such an abstract circumstance were to exist, it may be possible to provide care with no concern for the opportunity cost and comparative implications of a singular, individualised care plan. However, individual health needs rarely exist in isolation. As such, healthcare practitioners, irrespective of their geographic location, are pressed to consider other features relevant to the provision of healthcare services to the wider community (Hunt, 2011). With this in mind, concern for decision-making processes, the fair distribution of resources for health, and the rationing of healthcare has come to be recognised as a constitutive component of contemporary medical practice. Notwithstanding such globally generalisable observations, the most apparent difference between decision-making in a rural healthcare facility on the dynamic frontline of a conflict-affected country, and decision-making in a well-resourced, financially solvent hospital in a high-income country is that thresholds for rationing are surpassed more rapidly in the former, and that pressure to make decisions is therefore experienced earlier and more intensively in the resource constrained context.

Such considerations naturally pose a challenge for humanitarian healthcare providers, whose commitment to a particular patient is destabilised by the need to share concern for other present and potential future patients. Similarly, this commitment is further tested by an inability to meet patient needs consistently and comprehensively in many contexts. As outlined earlier, the tension between individual and aggregate population needs is well established, and a source of repeated concern for many humanitarian healthcare providers. The need to make such choices can form the basis for a moral dilemma, from which may be derived moral distress and, if unresolved, ultimately moral residue.

Navigating the Semantics

Notably, Slim identifies a number of key distinctions between true moral dilemmas and what he refers to as tough choices (Slim, 1997). He identifies the following as tough choices that do not represent true moral dilemmas: a tough choice that wavers on uncertain evidence; a tough choice for which the moral reasons for or against action conflict with non-moral reasons; a tough choice between two good options; and choices that are not made between competing principles, but which are rather 'hellish choices'. In contrast, true moral dilemmas are defined by Blackburn as 'situations in which each possible course of action breaches some otherwise binding moral principle' (1994: 315).

Lepora takes this line of scholarship further in her study of compromise, defining compromise as a necessary trade-off between 'matters of principled concern – fundamental values, moral principles, personal agency, integrity, honour, rights, dignity' (2012: 3). The act of compromising necessarily requires the suppression of one or more matters of principled concern in order to satisfy another. As Hoffmaster and Hooker explain in their study of the selection process for renal transplantation, 'compromise aspires to satisfy each of the conflicting values, principles, or obligations partially and proportionately to its importance in the situation' (2013: 547).