Médecins Sans Frontières (MSF), also known as known as Doctors Without Borders, is known across the world as a provider of emergency humanitarian aid in response to war, disease, natural disaster, and exclusion from healthcare (“About MSF”). They push to be ethical, moral, and impartial, but the problem is, there are still people behind the decisions that the organization makes, and it begs the question: who gets to define what is ethical? MSF also treads carefully in order to respond appropriately to crises, but again, what entails a crisis? There is a danger in trying to define these convoluted components of humanitarianism, since the determinant is given the power to ultimately determine the value of a life.
When I search up the definition of “ethical”, the following results show up:
- following accepted rules of behavior : morally right and good
- involving or expressing moral approval or disapproval
- conforming to accepted standards of conduct (“Ethical”)
All of these definitions require ethics being “accepted” or “approved”, but it is virtually impossible to gain 100% approval on anything. Individual people make these decisions, and as seen in the article by Mirian Ticktin Where ethics and politics meet: The violence of humanitarianism in France, there are nurses who read files and meet with people in order to decide if their illnesses warrant citizenship. Like gatekeepers or admissions officers, these nurses are allowed to make a subjective decision, even when their backgrounds and past experiences can easily shape their compassion and who they choose to help (Ticktin). This leaves an incredible amount of room for variability, but can a standard be set on these decisions? Is it truly humane to allow citizenship to one suffering person, while ignoring another?
Similarly, MSF responds to international crises, but there has been uncertainty—even within the organization—about what appropriate responses to these issues are. As with almost all humanitarian aid, there are those two dreaded words: unanticipated consequences. MSF knows that a quick and temporary response to an emergency is crucial, but they have to leave as soon possible since dependence on this aid often hinders a country’s own progress. As said by an MSF administrator of Ugandan projects, “We don’t want to put a foot in the [local] hospital or we’ll be there ten years later” (Redfield).
Unfortunately, that’s exactly what happened in Syria.
In 2011, MSF responded to the Arab Spring in and around Syria by operating medical medical facilities and running field hospitals and clinics. Four years later, MSF is still involved, but is facing an entirely new problem: hospitals largely run by the organization are facing air strikes, and MSF members are being abducted by the Islamic State (IS). Six hospitals have been forced to close, and four ambulances were destroyed (“Syria”). Tens of thousands of people in and around Syria are in desperate need of aid, but MSF and other international organizations are severely restricted in the humanitarian aid and healthcare they can provide. The result is poor and unsafe conditions for refugees who must live in overcrowded spaces, subject to psychological distress. In order to tackle this issue, MSF brought in psychologist and psychiatrists to carry out consultations, but it is clear that problems are compounding onto each other and that thousands of people are still suffering (“Syrian Refugees”).
So then, what is the job of MSF and international organizations? Radfield’s Doctors, Borders, and Life in Crisis distinguishes between two Greek terms for life: zoe and bios. Zoe entails the simple act of living or being alive, while bios represents a life with a narrative, and perhaps in their current state, MSF can only provide refugees the simple act of living. Can it be called humanitarian if the people who are “saved” live in fear, uncertainty, and distress? When is it time to change our mindset from “this is all we can do” to “what we’re doing is not enough”?
Discussion Questions
- Compassion currently plays a role in decision making (with France’s Illness Clause and Syrian refugees). Is there any possible way to remove compassion from the equation or ensure decisions are impartial?
- In humanitarian work, is it enough to simply keep someone alive? Who holds the responsibility of keeping people physically alive and who holds the responsibility of ensuring these people have human dignity? How do we define dignity?
Works Cited
“About MSF.” Médecins Sans Frontières (MSF) International. N.p., n.d. Web. 05 Nov. 2015.
“Ethical.” Merriam-Webster. Merriam-Webster, n.d. Web. 05 Nov. 2015.
Ticktin, Miriam. “Where Ethics and Politics Meet.” American Ethnologist 33.1 (2006): 33-49. Web. 5 Nov. 2015.
Redfield, Peter. “Doctors, Borders, and Life in Crisis”. Cultural Anthropology 20.3 (2005): 328–361. Web.
“Syria.” Médecins Sans Frontières (MSF) International. N.p., n.d. Web. 05 Nov. 2015.
“Syrian Refugees Need Humanitarian Aid.” Doctors Without Borders Canada/Médecins Sans Frontières (MSF) Canada. N.p., 14 Aug. 2012. Web. 06 Nov. 2015.
Hi Thu! You were definitely on-point in your analysis of the implications of using compassion as a component of humanitarian work and decisions. In the case of the nurses in France, it meant deciding to help between two people whose suffering can neither be equated nor compared. In this way, variability is an inevitable byproduct.
At the surface, it might be tempting do away with compassion or partiality as a solution to remove this variability. Ironically enough, this may also have its own set of unanticipated consequences. Pulling from my own experience, compassion can be used as a powerful tool in motivating important and involved work. I am involved with Health Leads at Hasbro Childrens Hospital and have found that my own feelings and attitudes towards social inequalities have helped drive efficacy and motivation in my work. If I were to be a “robot” and remove compassion from my work, then helping underprivileged communities becomes an act with no motivating basis. It would spur neither me or others from engaging in the same work.
But as you noted, there is a danger in using compassion as a tool for humanitarian work when bias and stereotypes come into play: when one player does not engage in a certain script that evokes certain emotions or narratives, the humanitarian outcome may not be the same. Assuming impartiality, while retaining compassion, seems to be the key. But how to obtain that? In fact, it seems to be an almost paradoxical combination because to be impartial suggests pushing emotions to the side.
Perhaps a way to ensure more consistent use of compassion in humanitarian work is to increase the number of players involved in the decision. In the case of the nurses in France, it seems that the humanitarian decision of giving aid is source of incredible variability given that it is choice made by a wide range individuals. Although it’s not a suggestion without its own implications and issues, perhaps a start would be to make the humanitarian decision a group decision. In this way, emotions of the extreme are avoided (unless everyone’s emotions tend to the extreme) and more decisions can be made on a consistent basis. Of course, this does not meant that the decisions will suddenly be fair or evade the issue of zoe vs bios–it simply means that emotions will still play in motivating work, but be used toward a more consistent, and hopefully productive measure.
Hi Lily,
I completely agree that compassion and emotion are very strong motivational forces for people to get involved and engage in humanitarian work. I have heard a lot about, as well as applied for Health Leads, and through talking to other current Health Leads members, I can see that personally caring for patients pushes people to do their best work.
I think it’s valuable to consider that having more people be involved in decision making is important when emotions can easily sway choices. The idea of averaging out opinions can be good, and much more consistent. This obviously requires more people and more work, which may be a reason why not every organization can have teams of people making every decision.
Hi Thu,
You raised an important question of whether it’s possible for a humanitarian group to be completely impartial since the act of making decisions (regarding health) warrants someone (in power) to make a decision about what is ethical. I don’t have the answer to this, but I agree that this decision-making is dangerous because it can determine not only the value of someone’s life, but also whether someone receives help or not.
Regarding your first question, I think it would problematic to completely do-away with compassion in decision-making. After all, compassion is perhaps the greatest force that drives people to help in the first place. I agree with Lily’s suggestion of increasing the number of people (and thereby increasing the diversity of backgrounds) involved in the decision-making behind humanitarian work. The inclusion of several people and several perspectives may actually broaden the population that an aid group is attempting to help; this is because everyone has inherent biases that guide their compassion. For your second question, I do not think it is enough to keep someone alive – though I do believe that this is a critical feat of humanitarian aid. However, like we discussed in class, and like other blog posts this week mentioned, it is equally important to also combat the structural violence that is causing health inequalities. This is the only way real change can occur; it is the only way we can integrate ‘zoe’ and ‘bios.’
Another subject I contemplated after reading your blog is the problem of “what defines a crisis?”. Last semester, I took a class called Anthropology of Disasters, and we talked about this topic a lot. Society often assigns a discrete time interval to an emergency (i.e. they define when the emergency/disaster begins and ends), but this method fails to acknowledge the contextual (historical, social, political, etc.) forces that have contributed to the disaster/people’s ability or inability to recover from the disaster. Furthermore, this method of assigning dates becomes difficult when – as discussed in class – an emergency does not have an ending. For example, one could say that Hurricane Katrina occurred on a specific date; since rebuilding is still taking place today, however, has the emergency ended, or is still ongoing? Additionally, reducing the disastrous effects of Hurricane Katrina to a mere time frame this would be ignoring the fact that people’s socioeconomic and racial status greatly influenced whether or not they could receive help. Moreover, this method ignores the historical processes that formed those socioeconomic backgrounds. Overall, like you implied, this raises several questions: Can we define a crisis? When has a crisis ended? And in the case of MSF, which crisis is more important to respond to?
These are the difficult uncertainties that groups like MSF must grapple with, and I think in a world where so many horrendous events and inequalities are occurring and where so many “crises” are occurring, the potential answers to these questions are blurred. But I think these are the questions that make it so important for humanitarian organizations to focus not only on saving lives, but also on improving lives (and I believe that these are not mutually exclusive objectives).
Hi Nini,
Thank you for your reply! I really appreciate the perspective you were able to bring in from your Anthropology of Disasters class, and it made me think for a while about the time frame that we give to disasters and “crises”. Many of the disasters that we hear about seem to disappear and we tend to think there are solved just because we don’t hear about them on the news or on social media. It is so critical to realize that people are still suffering, and organizations are still struggling to help. I also began to think of all the crises we don’t hear about and the countries that don’t get as much aid, and like with compassion, I want to question who gets to make a decision about what entails a crisis, and why do they get to choose? Even with a group of people working together to make a decision, not everyone is always going to have a fair input, and it’s hard for me to imagine how difficult it is to know that so many lives are depending on one decision.
Hi Thu,
This is a really interesting question you’ve raised, and it makes me think of the lecture with Professor Reynolds. On one hand, outsiders viewed guinea worm as a completely medical emergency. On the other hand, the people of Ghana did not consider guinea worm as a crisis but rather as a burden (they had other fatal medical issues to consider). I think this example shows us that those with privilege — whether it’s status, education, money, or country of origin — are the ones who decide whether something is a disaster or not… And their decisions about how “bad” something is are governed by their relative experiences.
Hi Thu,
I did not know much about MSF involvement in Syria, so the information you provided on this topic was very educational to me – thank you! Although I see why MSF wants to define itself as apolitical, I also find it slightly ironic. Just because MSF says that they are apolitical does not mean that politics will not “act” on them. As you state in your blog post, MSF individuals have being abducted and killed by warring factions. To a degree, that is “involvement” in politics that cannot be denied.
Your post also made me think a lot about what it means to be in crisis. Humanitarian efforts have decided that, by definition, crisis is short-term. However, I do not know if I agree with that. I wonder how these humanitarian efforts finally decide that a community is no longer in crisis. After an acute situation like a war or natural disaster, something significant is still left behind. I think back to the nightmares of the people in Aceh. Technically the people were no longer in immediate danger. However, the people were still tremendously suffering psychologically – are these people not in crisis? Furthermore, I would argue that people suffering physically and mentally on a daily basis from structural violence are constantly in chronic state of crisis. Just because it is longer-lived does not mean it is not an emergency, right?
Maybe if the meaning behind “crisis” was thoroughly discussed, humanitarian efforts may realize that they are addressing only a small aspect of the issue at hand. However, as has been stated time and time again, many of these problems are too complicated to be fixed swiftly and without additional repercussions. So for now humanitarian groups rigidly restrict themselves to these immediate situations, situations that may only reflect a small part of the umbrella term “crisis”.
Hi Derana,
It’s very true that even if an organization says they want to stay out of political issues, it doesn’t mean these issues won’t find them, and it is difficult to stay out of politics when it is so integrated into health and infrastructure. It was idealistic for MSF to want to be apolitical, but as we know, rarely does everything go as planned.
For MSF to say they respond to crises does mean they have to decide what a crisis is, which brings up all the questions we are discussing now. I also began to think of Partners in Health, and how they try to integrate crisis relief with long term infrastructure support to take a more diagonal approach. In this case, they avoid putting a deadline on their goals. Not all organizations aim to do the same, but maybe this could be a better approach to ensure a crisis isn’t left unsolved.
I echo those before me in regards to the importance of compassion. Compassion can be a strong force in enacting change where policies have not. However, as you pointed out and as was discussed in Tinker’s article, compassion can be racist, sexist, unjust, and inconsistent when it favors certain bodies over others. Yet by aiming towards impartiality, this runs the consequence of erasing personal stories, experiences. It seems that certain qualifiers would have to be established to achieve impartiality, but what are these qualifiers and who gets to decide them? To get to impartiality requires subjectivity.
I agree with Lily, perhaps a better solution is to involve more people in the decision-making process not necessarily by quantity but quality (people from diverse backgrounds and fields). Having many nurses engage in the decision-making process may not be as productive as having a couple of them along with economists, policy-makers, social-workers, psychologists, etc. Doctors and nurses prioritize health, for obvious reasons, yet other factors and actors are important towards promoting the wellbeing of a person and the country as a whole. In Tinker’s examination of France, political decisions regarding immigrant citizenship are left in the hands of medical actors alone. Yet the medical perspective is not enough. Their goal, for obvious reasons, is to keep people biologically alive through medical treatment. However, education, shelter, nutrition, money, job security, etc. are other important aspects of health that take one from being a zoe to a bios. By including more people in the conversation, this could have the benefit of addressing these other aspects and coming to a sound agreement on the best course of action to take, one that encompasses a multitude of factors that go into health/wellbeing.
Hi Jeannette,
I like that you emphasize quality over quantity, because even having a large number of people from the same background and past experiences will result in the same skewed decisions. However, having a group of people from all different backgrounds may lead to opinions being so diverse and so radical that a decision may not be able to be made at all. Decisions about a person’s or peoples’ lives need to be made quickly, and if people are too different, it might take too long to come to a succinct conclusion. Maybe a balance needs to be struck between people who work together to examine issues of health, or sacrifices in diversity have to be made in favor of efficiency.
I think that your question of where ethical decisions come from is really interesting, and begs consideration of what value systems groups like MSF or Partners in Health come from. Even many western medical ethics have roots in religious considerations of the body, and the way that this ethical knowledge is reproduced is particularly intriguing to me. I appreciate your point that the determinant of ethical acts and of “crisis” are the ones implicitly given power to place a value judgement on another body, and one must also ask the ethical implications of that. Who decides what ownership one body has over the fate of the next? How does humanitarian aid navigate it’s clearly colonialist roots of power and racial inequity?
The idea of the gatekeeper model of health care determination (with regards to who is let across borders) and the discussion of biological citizenship is very interesting to me. Ultimately, your question regarding the humanity of selective citizenship brings into question the idea of triage most generally: how does one place the value of one body over the other? This reminds me of the 0-1 scale that Prof. Mason brought up in class, with 1 being death and 0 being full life, and the implications of what it means to be a 0.7 vs a 0.4 (do you provide benefits to the 0.4 in order to sustain their life or to the 0.7 for curative ends?)
Hi Dolma,
I was thinking a lot about the obvious colonial roots of western medicine, because the people in power to make these decisions about inequality, race, and gender tend to be in power by past or even present unequal, racist, and sexist means. It is dangerous not to have more diversity and more input from people who historically have not had a say in the structure of health.
Thinking about health in the terms of the number scale you mentioned is interesting, because it almost brings up the topic of zoe and bios. Should efforts be made to bring everyone to at least a 0.4 and stay there, or help some people get to that 0.7 (or even 1.0)? The end goal would be for there to be enough people and resources to get everyone up to a 1, but unfortunately, I know that’s very optimistic thinking.
Thu,
I really appreciate the inquisitive nature of your post. You push me to think about humanitarianism in an even more multifaceted way than we have in the readings and in class. I especially admire that you expressed the “danger in trying to define these convoluted components of humanitarianism,” because inevitably by defining this loaded term, we will exclude something else from that definition. Your question of who defines what is ethical particularly resonates with me, because I realize that as we are the students in an International Health class, perhaps it will be us one day that decides what is and what is not ethical. To answer your question, perhaps humanitarian groups should incorporate the values and ethics of the local community into what they determine to be ethical, since they are the people whose livelihoods are in their hands.
I’d like to focus on your second question. In more philosophical terms, no, it isn’t enough to just keep someone alive. As in the American Constitution as well as many other national doctrines throughout the world, people are thought to deserve “the right to life, liberty, and the pursuit of happiness.” It is tragic, then, that it is not in the nature of humanitarian organizations to deliver those rights.
It’s quite a hard task to define dignity. Like you said, whoever is given the power to define such broad yet important terms ultimately determines the value of a life. Perhaps we should limit our definition of dignity to be the maximum amount of agency and freedom that a person can have, so that there is a general enough definition to include all aspects of what can be interpreted as dignity.
Hi Sarah,
I hadn’t thought about how many national doctrines in the world do focus on more to life than simply surviving, but it seems that life comes first, and when the first step can’t be taken, it makes it vastly more difficult to skip to the next steps.
I like that you thought about adhering to the local community’s ethics and morals, because in the end it is them that we are trying to help. What they deem to be moral and ethical should be much more important than the arbitrary definitions we set up.
It’s terrifying, but also motivational and inspiring to think that by starting here and taking this class, we are exposing ourselves to these issues and could be making these decisions in the future.
I really like how you intertwined currents into your argument. I think the events in Syria demonstrate the limitations of MSF. NGO’s like Partners in Health intervene areas that generally have a somewhat stable government in place, that makes attempting horziontal approaches possible. However in places like Syria, making change beyond saving-lives seems nearly impossible. MSF isn’t working in an environment stable enough to approach issues structural violence. It’s hard for me to expect them to go beyond the zoe in situations where they themselves are at risk. I think the only way to attempt saving personhood is through the intervention of international governmental bodies, that would have the power and the resources to hep refugees attain some sense of dignity.
Hi Hacheming,
You’re definitely right, there are big differences in where MSF and PIH are working, and it’s naive to overlook the differences in the problems different countries are facing. Does this mean we should focus on zoe and keeping people alive until the situation is deemed stable enough? I would venture to ask what does “stable” mean, and how do we know when it is time to focus on more than just keeping people alive? How long would that take?
I really appreciate the different viewpoint you presented, and it makes me take many more factors into consideration when analyzing the actions of NGOs.
Hi Thu!
I thought you wrote a really good post, and I thought that I would share my thoughts and recommendations to your questions.
Your topic reminded on ethical discrepancy reminded me of the Essential Medicines topic we talked about a couple weeks before your post. Organizations such as the WHO were debated ‘essential vs. non-essential’ medicines, but who is to say what is essential and what is not? What might be essential to you might not be essential for someone else. I think this raises an important concern because leaving decisions up to whoever can result in mistakes and biases that could be fatal.
Overall, I agree with Jeanette to which rules or a list can create less flexibility and detach us from personal experiences, but I think this would be the most justified way to handle this situation. However, I think that these can be exceptions to any rules especially including someone’s health-life or death situations.
Your second question is very difficult to answer. It is easy to say, “If they are going to die soon, it isn’t worth the time and money etc.” But once you are placed in this situation it’s extremely difficult. Ultimately, I think this decision should be placed on the patient—assuming that the patient is fully aware of his or her conditions.
Hi Samantha,
It seems like defining terms such as “essential”, “crisis”, or “humanitarianism” is extremely difficult, because everyone attaches a different meaning to each word, and each carries a set of values that are all valid. People in a position to make these decisions about the value of a life must weigh the consequences–both positive and negative–and most likely consider the possibility of making a mistake.
Your comment at the end reminds me of Singer’s utilitarian approach, and how some might think it doesn’t seem worth the time or effort to save someone’s life if they are going to die soon. Though pragmatic, it rightfully makes many people uncomfortable, and though occasionally it would be possible to put the choice in the patient’s hands, that isn’t always possible.
Hi Thu,
Thanks for posting, I liked your ethical analysis and historical context on the relation between MSF and current conflicts in and around Syria. I agree that MSF’s goals – to be motivated by ethics, rather than politics or economics or efficiency, is a difficult stance to fully understand or justify. As you said, there is no universal ethical code, so these motivations will necessarily be biased and directed. And while ethical motivations are not synonymous with compassionate ones – these suffer from similar criticisms. Choosing one framework of ethical analysis over another can make the difference between whether an action is considered justified – or even praiseworthy – or not. Your example of whether or not deciding someone’s illness warrants citizenship is a great example of this limitation.
To respond – when questioning whether ethics or compassion are appropriate motivators for NGO action, we need to consider what alternative motivators we would prefer. To me, the stance that MSF is ethically driven simply means they strive to be apolitical. Whether their actions accomplish that goal is another question. Regardless of your motivations, not everyone will agree with your goal, so I believe that being driven by a personal sense of compassion seems as valid as any other appropriate goal – and again, the concern that remains for me is whether their actions ultimately are in line with their proposed interests. It is also difficult – fair but difficult – to question organizations on the premise that they did not do enough. While dignity is, in my mind, a human right, one that is immensely important to protect, the ultimate question you ask here is who holds the responsibility to protect it. The worry with one organization attempting too much is that it delivers a subpar outcome with one or all of its sub-goals.
Hi Jacob,
Thank you for your comment! The debate on what being ethical or moral is likely always going to be present, because as convoluted as these terms are right now, I think they are vulnerable to change as human values change. Societal expectations have undoubtedly changed over the years, and there is nothing stopping what we consider as “moral” to change as well.
I agree with what you say about MSF’s goal to apolitical by being more ethically driven, and that it is nearly impossible to have everyone agree with a decision. Having achievable, clear set goals means not covering every single issue, but it may be better to completely address one issue rather than try to have a foot in every issue and fail.
Hi Thu,
I really liked your analogy of the nurses in France as “gatekeepers or admissions officers.” The subjective nature of deciding who is worthy of care is extremely problematic and you did a great job exploring this. This brings us back to the DALYs and our discussion of how placing value on one life on such a scale, over another is a slippery slope to Singer’s utilitarianism.
A huge grey area that you discussed was who gets to decide and what previous biases does that person/organization bring to the table with them that affect who they deem worthy of care?
Hi Jessica,
I realized that being gatekeepers is a very difficult task, and is a huge responsibility. I do have to acknowledge that these people are making the best decisions they can based on what they know, so it is hard to criticize them for that.
Previous biases definitely play a role in decision making, and I wonder if sometimes these biases are good, since they allow people to connect on a personal level. As in many of the comments above, I do think that a balance of a few people with different backgrounds to lead to a more averaged decision.