Challenges to ethical obligations and humanitarian principles in conflict settings: a systematic review

Abstract

Background

Humanitarian health care organizations and health workers working in contexts of armed or violent conflict experience challenges in fulfilling ethical obligations and humanitarian principles. To better understand the types of challenges experienced in these contexts, we conducted a systematic literature review.

Methods

A broad search strategy was developed for English language publications available in PubMed, Ovid/EMBASE, and Scopus. The search relied upon three key concept blocks: conflict settings, humanitarian or relief organizations, and non-clinical or non-military ethics. To be included, publications had to (1) refer implicitly or explicitly to ethics and/or humanitarian principle(s), (2) relate to non-military relief work in active conflict or conflict-affected settings, (3) relate to organizational mission and/or delivery of services, and (4) relate to events after 1900. Records were qualitatively analyzed using an emergent thematic analysis approach that mapped challenges onto recognized ethical obligations and humanitarian principles.

Results

A total of 66 out of a possible 2077 retrieved records met inclusion criteria. The most frequently noted ethical challenges for organizations working in conflict settings were (1) providing the highest attainable quality of care, (2) protecting workers, and (3) minimizing unintended harms. The humanitarian principle most frequently noted as challenging to uphold was neutrality (the duty that humanitarian actors must not take sides in a conflict). Ethical challenges and humanitarian principles were commonly co-coded. For example, the challenge of providing the highest attainable quality of care frequently intersected with the humanitarian principle of humanity.

Conclusions

By categorizing the types of ethical challenges experienced by humanitarian care organizations, this review can help organizations anticipate issues that might arise in conflict settings. The identified relationships between ethical challenges and humanitarian principles suggests that frameworks and guidance for ethical decision-making, if adapted for conflict settings, could support organizational capacity to fulfill ethical and humanitarian commitments.

Introduction

Humanitarian health organizations and health workers frequently work in conflict settings where they are subject to direct attack and where active armed conflict disrupts basic institutions and provision of services. Violence against humanitarian health workers, which may result in death, is a persistent and pervasive contemporary problem (Humanitarian Data Exchange (HDX) 2019; Safeguarding Health in Conflict Coalition (SHCC) 2018). Syria, in particular, has been called “the most dangerous place on earth for health-care providers” (Fouad et al. 2017).

Violent attacks against humanitarian health organizations and workers have many negative consequences. Health workers may suffer bodily injury, psychological harm, economic loss, and even death. Attacks can destroy hospitals and other facilities, disrupt delivery of essential supplies, interrupt service provision, and/or cause an organization to leave. Violent attacks can also discourage extending humanitarian assistance to where it is most needed.

Violent attacks not only violate international law (Rubenstein and Bittle 2010); they also create ethical challenges (Slim 2015). Health workers functioning in conflict settings may be faced with sudden and difficult decisions, including whether to practice outside their scope of training because of personnel shortages, how to deliver care when resources are limited or unreliable, which patients to treat when resource or security constraints prevent equal access, and how to maintain impartiality in providing care to both the victims and perpetrators of attacks, among many others. Humanitarian health care organizations face similarly challenging ethical issues, such as whether to rebuild destroyed facilities in more remote locations (which may negatively affect access), whether to focus special attention and resources in reaching vulnerable groups (when doing so might be detrimental to serving the most people possible), how much risk they can allow for their workers, and how to remain independent in the face of demands by combatants and donors.

Nevertheless, the full range of ethical and humanitarian challenges experienced by humanitarian health organizations—especially in conflict settings—has not been described. Understanding that range is essential for developing strategies to better manage them, but existing systematic reviews have not focused on ethical issues specifically (Chaudhri et al. 2019). In addition, whether existing frameworks for ethical decision-making in humanitarian action (Clarinval and Biller-Andorno 2014; Fraser et al. 2015) might apply or be useful in settings where health care workers and facilities are themselves subject to persistent attack remains unknown. To begin filling these knowledge gaps, we conducted a systematic literature review of the ethical and humanitarian challenges experienced by humanitarian health organizations in conflict settings. This systematic review is part of a larger project examining (via interviews and workshops) the organizational- and individual-level ethical challenges that humanitarian organizations have faced during the Syrian conflict.

Methods

Search strategy

Working with a research librarian, we developed a broad search strategy utilizing three core concept blocks: (1) conflict, (2) humanitarian or relief organizations, and (3) non-clinical or non-military ethics. We chose search terms for each concept block using controlled vocabulary and key terms with iterative search yield analyses. The first concept block included 13 search terms: “conflict,” “war,” “wars,” “warfare,” “revolution,” “revolutions,” “Arab spring,” “uprising,” “uprisings,” “cruelty,” “cruelties,” or “high-risk environments.” The second block consisted of seven search terms: “relief,” “relief work,” “aid,” “humanitarian,” “humanity,” “NGO,” or “NGOs.” The third block included nine search terms: “ethics,” “ethical,” “morality,” “professionalism,” “professional duties,” “neutrality,” “principles,” “independence,” and “accountability.” The full search strategy can be found in Additional file 1: Appendix 1.

Screening process

Three databases were searched: PubMed, Ovid/EMBASE, and Scopus. The searches returned 442 records in PubMed, 699 in Ovid/EMBASE, and 929 in Scopus. Titles and abstracts were independently screened by two study team members. To be included for full-text review, publications had to have an available full-text version, be published in English, and address all three key concept blocks. Publications that described only clinical ethics issues (e.g., truth telling or informed consent) that were not strictly related to a conflict setting were excluded; this ensured a consistent focus on those issues salient to, and arising in, conflict settings. Similarly, we excluded military ethics as not germane to humanitarian practice.

During full-text review, we applied the following inclusion criteria. To be included in qualitative analysis, a publication needed to (1) include reference, implicitly or explicitly, to ethics and/or humanitarian principle(s); (2) relate to non-military relief work in active conflict or conflict-affected settings; (3) relate to organizational mission and/or delivery of services; and (4) relate to events occurring in the twentieth century or later. To supplement the database searches, we also reviewed the reference lists of included publications. Disagreements about inclusion between the two initial reviewers were adjudicated by one or more additional study team member(s).

Data coding and abstraction

Two study team members qualitatively analyzed the included articles using a thematic editing style (Campbell et al. 2011). Data were managed using NVivo software (QSR International Pty Ltd., Version 11.x, 2017).

First, a preliminary codebook was developed based on an informal review of the literature (Additional file 1: Appendix 2), the research team’s experience and knowledge of the field, and consultation with experts in related areas of humanitarian ethics research, such as ethical issues that emerged in responding to the 2014–2015 Ebola epidemic. This preliminary codebook included two primary categories (i.e., “Ethical obligations” and “Humanitarian principles”). Within these categories, nodes were created to accommodate specific obligations and principles; within these nodes, subnodes were created to capture specific challenges to fulfilling the obligations and principles.

The “ethical obligations” category drew upon existing literature on ethical issues for humanitarian organizations and humanitarian health practice generally, in pandemics (e.g., influenza and Ebola [Kass et al. 2019]), in conducting research on sexual violence in emergency situations, and other areas (see Additional file 1: Appendix 2). Although ethical obligations of humanitarian health organizations and health workers may overlap, the focus of the codebook was the organizational level.

The “humanitarian principles” category drew upon the four widely accepted humanitarian principles: neutrality, impartiality, humanity, and independence (General Assembly resolution 46/182 1991; General Assembly resolution 58/114 2004; Pictet 1979; Sphere Project 2011). Neutrality is the duty that humanitarian actors must not take sides in a conflict. Impartiality stipulates that humanitarian actors must not discriminate or give preference to any nationality, race, religious belief, class, affiliation, or political opinion. Humanity means that human suffering must be addressed wherever and for whomever it is found. Independence demands that humanitarian actors retain their autonomy and remain independent of political or military objectives of other actors.

By employing these two main categories, we do not mean to imply that humanitarian principles and ethical obligations are fundamentally different in kind; at a high level, both are normative (i.e., they indicate what should or ought to be done). Our decision to differentiate them for analysis was motivated by three considerations. First, humanitarian principles and ethical obligations have different descriptive origins. Humanitarian principles originated more recently in operational, legal, and ethical frameworks for the Red Cross movement in its humanitarian activities; they have since been adopted by the United Nations and humanitarian organizations. Two of the principles, humanity and impartiality, provide what has been called “a moral ideal” for humanitarian action, while neutrality and independence are “practical tools for making humanity and impartiality a reality” (Labbé and Daudin 2016). Second, based on our initial literature review, the humanitarian and ethics literatures infrequently connect to each other; one goal of our review was to elucidate those connections in the peer-reviewed literature. Third, in practice humanitarian organizations and workers may view and use humanitarian principles and ethical obligations differently; this assumption was later borne out in workshops we conducted as part of the larger project. In these workshops, for example, attendees viewed humanitarian principles more as motivating ideals, whereas ethical obligations were viewed as more specifically action-guiding.

Second, the preliminary codebook was used by two study team members to review ten randomly selected full-text articles. After independently reviewing the articles, the study team members met to discuss and resolve category coding differences. At this stage, two major additions were made to the codebook. In the “ethical obligations” category, the obligation of appropriate acquisition and management of assets (including financial, material, and human assets) was added as a node (Civaner et al. 2017; Hunt 2008). In the “humanitarian principles” category, the principle of “solidarity” was added as a node, as it was noted to be an emerging humanitarian principle. In the literature, solidarity has been defined in different ways to include concepts of political advocacy, human rights, shared suffering, and consultation with those affected (Hunt et al. 2014; Hurst et al. 2009; Omaar and de Waal 1994; Slim 1997a, b). In light of solidarity being a more recently emergent principle lacking a single standard definition in the literature, for the purposes of coding, we employed a broad conception of solidarity that encompassed all of these possible uses.

Third, the two study team members used the revised codebook to re-code the same ten articles, and results were compared. The comparison revealed differences related to length of text coded and frequency of coding, but not the presence or absence of nodes. Satisfied with the reliability of coding, the two study team members proceeded to independently code the remaining articles. Text passages were coded line-by-line using this scheme. Passages that were difficult to interpret were discussed and coding was reconciled through discussion among the entire study team.

The two primary categories were not mutually exclusive. Given the nature of our subject matter—ethics and humanitarian principles in conflict settings—and our goal to describe and categorize the range of issues arising, we did not assess the “quality” of included articles overall or of any specific statements or arguments presented.

Results

This search yielded 2077 records. After 451 duplicates were removed, and 1537 records were excluded during abstract and title review, 89 articles were selected for full-text review. Of these, 23 did not meet inclusion criteria. Reference list review yielded an additional seven publications. In total, 66 articles met inclusion criteria and were included in the analysis (see Fig. 1 for the study flow diagram and Additional file 1: Appendix 3 for the list of 66 included articles).

Fig. 1

Search flow diagram

A full summary table of qualitative findings with representative quotations can be found in Additional file 1: Appendix 4. Below, we present key summary findings. In reporting numbers, “N” refers to the total number of articles with the code applied, and “n” refers to the number of individual coding instances (i.e., a single article could include multiple coding instances).

Ethical obligations

Table 1 presents findings related to ethical obligations. The organizational ethical obligation most frequently coded was providing the highest attainable quality of care and services. This obligation was discussed in 52/66 (79%) of sources and was also the most frequently assigned code. Challenges to fulfilling this obligation included disruption in available supplies and services, difficulty getting supplies and services to the front lines (even when they were available), and a perceived lack of accountability for quality of care (e.g., documented impact, quality reporting, and so on).

Table 1 Coding frequencies of ethical obligations, including the top coded challenges

Appropriate acquisition and management of assets (i.e., informational, financial, and human assets) was an ethical obligation that emerged in the analysis. This obligation operated at the organizational management level (e.g., when an organization faces difficulties in maintaining a stable workforce).

The third most frequently coded obligation related to protecting and caring for workers (i.e., the “duty to care” in the humanitarian literature). The duty to care can be a legal obligation that employers must meet regarding their employees. In humanitarian settings and more broadly from the standpoint of ethics, it more commonly refers to the recognized ethical obligation of organizations to foresee, prepare for, and mitigate the impacts of working in a complex, stressful, and sometimes dangerous environment. A particular challenge related to this obligation was concern over “risk transfers,” or situations where organizations might seek to mitigate their own risks or risks to their workers by transferring them to others (e.g., by assigning certain tasks to local individuals).

Humanitarian principles

Table 2 summarizes findings related to humanitarian principles evident in the literature reviewed. Neutrality was coded most frequently. A significant challenge to neutrality was the idea that aid itself could be perceived as political. For example, when an aid organization works closely with a local population, that association could be perceived as compromising neutrality if the local population is perceived to be on one side of the conflict.

Table 2 Coding frequencies of humanitarian principles, including the top coded challenges

Challenges to the principle of independence were also prevalent. For example, organizations’ commitments to independence could come into question due to political or financial ties with state agencies, non-state groups, or donors that might restrict an organization’s activities, even if these ties were merely perceived. Non-transparency related to budgetary or programmatic decision-making was another commonly coded situation where independence could be in question.

Regarding impartiality, pressure on organizations to show favoritism to one group over another was the most frequent subnode. For example, some sources described situations where organizations were forced to choose between losing access to an entire population or yielding to demands of armed groups to give preferential treatment to their members. Even without this type of overt pressure, humanitarian health organizations could sometimes be compelled to concentrate aid work in safe or more easily accessible areas.

The intersection of ethics and humanitarian principles

As described in our methods, coding of humanitarian principles and ethical obligations was not mutually exclusive. Table 3 displays the frequency of co-coding these two categories; Table 4 illustrates this intersection with five examples.

Table 3 Intersections between ethical obligations and humanitarian principles

Table 4 Examples that illustrate the potential intersection between humanitarian principles and ethical obligations

In some instances, this intersection was found to represent apparent tension between fulfilling humanitarian principles and ethical obligations. For example, the ethical obligation to support a locally-led response could be in tension with the humanitarian principle of independence when local community members are aligned with one side of the conflict or another. Similarly, the ethical obligation to provide honest and transparent communication could be in tension with the principle of independence, for example, if distributing communication relies upon state-owned media. In other instances, this intersection was found to be mutually supportive. For example, the ethical obligation of ensuring a fair distribution of the benefits and burdens of aid supports fulfilling the humanitarian principle of impartiality. We explore the relationship between ethical obligations and humanitarian principles further in the “Discussion” section.

Management strategies

While not the focus of our review, coders did make note of strategies organizations used to attempt to manage identified challenges. Without endorsing these as the best or only correct strategies, these are listed in Additional file 1: Appendix 4. We highlight several here.

Some organizations have responded to the obligation to protect workers, for example, by creating secure operational sites with minimal and/or strictly controlled access to the outside world (a strategy known as “bunkerization”). Such a strategy can protect workers, but may occur at the expense of another obligation, i.e., involving locals in operational planning and management. By contrast, for example, some organizations have created formal decision-making processes inclusive of all stakeholders, including aid recipients, for the sake of transparency and to facilitate incorporation of local knowledge and norms. Regarding humanitarian principles, for instance, some organizations have maintained independence by refusing to accept funds conditional upon particular program changes or by investing and developing their own asset management strategies to avoid reliance upon, or sharing assets with, partisan groups. Such an approach maintains both real and perceived independence.

Discussion

This systematic review yielded three principal findings related to ethical and humanitarian challenges experienced by humanitarian health organizations in conflict settings. First, the relative frequencies of the ethical obligations and humanitarian principles described provide insight into the types of issues organizations are likely to encounter. Second, our findings have identified common ways in which ethical obligations and humanitarian principles can be mutually challenged in conflict settings. Third, by identifying points of overlap between ethical obligations and humanitarian principles, this review could motivate exploration of innovative approaches to meeting these challenges (e.g., by exploring whether management of ethical challenges could help organizations better fulfill humanitarian principles).

Ethical obligations and challenges

In our review, the most commonly identified challenges to providing the highest attainable quality of care and services involved logistical obstacles such as disruptions or shortages of food or medical supplies, personnel, or care services and difficulties getting medicine and providers to front lines to meet communities’ needs. Challenges to this obligation, founded on the ethical principle of beneficence, include disparities in the availability of facilities and supplies in conflict settings as compared to that of many workers’ home contexts (Baskett 1994; Bernthal et al. 2014; Civaner et al. 2017; Hunt 2008; Hunt et al. 2014), the existence of counterfeit or low-quality supplies and medications (Burkle Jr. et al. 2017; Michael and Zwi 2002), and policies restricting the administration of care to select populations and blocking access to certain locations (Al-Moujahed et al. 2017; Civaner et al. 2017; Clarinval and Biller-Andorno 2014; Fouad et al. 2017).

Our findings also highlight an additional dimension to the duty to provide high-quality care: accountability. Fulfilling the obligation to provide high-quality care requires explicit evaluation of outcomes, without which the quality cannot be assured (Al-Moujahed et al. 2017; Burkle Jr. et al. 2017; Civaner et al. 2017; Clarinval and Biller-Andorno 2014; Fouad et al. 2017).

Even when organizations attempt, at a minimum to meet their duties of beneficence by avoiding causing harm, they could face challenges in doing so. Organizations may fear that providing aid could unintentionally sustain conflicts (Banatvala and Zwi 2000; Black 2003; Clarinval and Biller-Andorno 2014; Duffield et al. 2012; Fink 2007; Gardemann 2002; Hunt 2008; Michael and Zwi 2002; Poffley 2012; Slim 1997a, b). Moreover, there were concerns that humanitarian aid could destabilize established in-country health and other support systems and create unsustainable programs that result in support gaps when aid programs depart (Hunt 2009; Jaspars and O'Callaghan 2010; Rieffer-Flanagan 2009). Lack of training for workers (especially in disaster- or conflict-specific competencies) was cited as leading to inadequate or inappropriate care for vulnerable populations and forcing workers to make ad hoc decisions about triage and prioritization of patients and treatments—resulting in suboptimal care (Civaner et al. 2017; Fouad et al. 2017; Joshi et al. 2008).

Challenges related to the appropriate acquisition and management of assets arose from informational and financial factors. For instance, a lack of interorganizational information sharing (Haver 2016) or an inability to attain necessary information due to operational restrictions (Bernthal et al. 2014) could make it more difficult to manage material and personnel resources when delivering aid. Financially, for example, external constraints related to the need to maintain relationships with existing and future donors (Cobey et al. 1993; Gastineau Campos and Farmer 2003; Haver 2016; MacCormack 2007; Weiss 2016) and internal constraints related to the need to sustain existing programs and staff (Michael and Zwi 2002) could affect organizations’ abilities to adjust resource management nimbly in response to ever-changing circumstances (Clarinval and Biller-Andorno 2014; Hurst et al. 2009; Leaning et al. 2011). The inability to recruit and retain skilled individuals can require organizations to fill essential staffing gaps with unqualified or untrained individuals (Fouad et al. 2017)—an action that could present a challenge to the provision of high-quality care.

Quality of care and resource management intersected the ability of organizations to realize an equitable distribution of benefits and burdens, an obligation of justice or fairness, and minimizing harms of a response. For organizations operating amidst resource shortages, in settings where local health systems have been destroyed, or with other critical limitations (Al-Moujahed et al. 2017; Gardemann 2002; Haver 2016), it is nearly impossible to treat all potential beneficiaries equitably or reach those most in need. Extremely dangerous security situations can result in providing aid preferentially to those in safer areas when, ideally, aid should be provided equitably to all and provided based on need (Clarinval and Biller-Andorno 2014; Egeland et al. 2011; Haver 2016; Leaning et al. 2011; Poffley 2012).

Organizations may also need to be aware of other sources of differential care that raise ethical concerns. These can include the personal prerogatives of humanitarian workers themselves (Ben Shahar 1993; Civaner et al. 2017), gaps in situational awareness that allow dishonest actors to present distorted views of needs (Fegley 2009; Gardemann 2002; Haver 2016; Hunt et al. 2014), and threats of violence or criminal prosecution against health workers (Blair 1996; Fouad et al. 2017; Haver 2016).

Protecting and caring for health workers (i.e., the “duty to care”) is another recognized obligation of humanitarian organizations. Advancements in operational security (Egeland et al. 2011) and a growing acceptance of increased danger in humanitarian endeavors (Duffield et al. 2012) may expand the breadth of humanitarian efforts in conflict settings, making this obligation ever more central. There is a growing appreciation of the organizational responsibility to protect its workers and acknowledgement of the diminished ability to provide quality care due to security concerns when organizations operate within conflict settings (Asgary 2015; Banatvala and Zwi 2000; Fouad et al. 2017). There is also a recognized need to ensure that health workers are adequately informed about these risks. To be sure, the obligation to protect workers is not the humanitarian organization’s alone; the international community, via international humanitarian law, also plays a role in protecting humanitarian health workers (Burkle Jr. et al. 2017; Fennell 1998; Fouad et al. 2017; O'Callaghan and Leach 2014).

Our review identified a specific ethical concern regarding one way organizations might protect their own workers: “risk transfers.” Risk transfers, which occur when international or non-local actors transfer dangerous assignments to individuals outside their organization, usually to local actors (thereby meeting another ethical obligation regarding involving local communities), could meet the organization’s obligation to protect its own workers at the expense of others’ safety (Egeland et al. 2011). Yet the ethical appropriateness of this practice has been to date underexplored.

Supporting a locally-led response is an obligation based on the idea of fair decision-making processes. The collapse of in-country health systems (Al-Moujahed et al. 2017; de Waal 2010; Michael and Zwi 2002); difficulty in identifying and trusting local leaders (Black 2003; Cobey et al. 1993; Fouad et al. 2017; Haver 2016; Weiss 2016); and tensions arising between organizational, individual, and local beliefs and norms (Civaner et al. 2017; Egeland et al. 2011; Fegley 2009; Fraser et al. 2015) all make fulfilling this obligation challenging.

Practicing honesty and transparency in communications was an important theme in our review. A notable challenge to honest communication was the perception that open communications could subject organizational assets to additional risks (e.g., by subjecting them to further attacks) (Redwood-Campbell et al. 2014).

Relationships among ethical obligations and challenges

Although the relationship between different ethical obligations was not typically explicit in the literature, we noted how ethical obligations could be either in tension or mutually supportive.

Regarding tensions, for example, the duty to provide the highest quality care (which could require significant resources) could be in tension with the duty to humanity, i.e., to relieve suffering wherever it was found (which could require devoting fewer resources but to more individuals in need). It is also possible that meeting some obligations, such as those regarding open communications, locally-led responses, and respecting cultural norms, could require dedicated resources and deliberate planning that might detract from efforts to provide aid to all in a timely manner (a tension experienced even if this short-term loss is made up with longer-term benefits regarding sustainability).

Ethical obligations can be mutually supportive, however. A commitment to engaging local communities in planning and aid efforts, for example, helps identify and minimize potential harms and unintended consequences as well as promoting respect for cultural norms (Egeland et al. 2011; Haver 2016; Hurst et al. 2009; Jaspars and O'Callaghan 2010; Tribe et al. 2014). Appropriate resource management strategies make it more likely that organizations can meet their obligations to deliver the highest possible quality of care (Banatvala and Zwi 2000; Blair 1996; Leaning et al. 2011).

The precise ways in which ethical obligations are in tension or are mutually supportive are context dependent. Identifying and mapping these relationships could help organizations manage ethical issues arising during operations.

Humanitarian principles and challenges

Our review identified that the primary challenges to neutrality were perceptions that humanitarian assistance was innately political (Fouad et al. 2017; Geiger et al. 1989; Madhiwalla and Roy 2009) and that the very act of working in conflict settings implied some type of political affiliation (Rieffer-Flanagan 2009). Military and political interventions operating under the guise of humanitarian aid can lead combatants or beneficiaries to doubt the neutrality of humanitarian organizations (Asgary 2015; Clarinval and Biller-Andorno 2014; Cobey et al. 1993; Duffield et al. 2012; Egeland et al. 2011; Gastineau Campos and Farmer 2003). Perceptions of non-neutrality can arise from using military escorts for protection (Egeland et al. 2011; MacCormack 2007; Poffley 2012; Slim 1995), the non-neutral conduct of partners (Egeland et al. 2011; Haver 2016), or if combatants insert themselves between humanitarian actors and aid beneficiaries (Fegley 2009).

Maintaining neutrality can also be difficult for organizations whose workers have experienced violence, threats, or compulsion, or have borne witness to violence or advocated on behalf of victims of atrocities (Blair 1996; Burkle Jr. et al. 2017; Civaner et al. 2017; Farré 2013; Geiger et al. 1989; Slim 1997b). Organizational members’ own personal political views could also affect perceptions of organizational neutrality (Jones 2009). Humanitarian organizations operating in resource scarce settings can also be perceived as lacking neutrality because of how they allocate resources and maintain secure access to those in need. Organizations can inadvertently or unwittingly become affiliated with other political objectives, for example, if they capitalize upon access gained by other, partisan groups, or use security services (e.g., formal military support) (Black 2003; Clarinval and Biller-Andorno 2014; Egeland et al. 2011; Gastineau Campos and Farmer 2003; Haver 2016; Mačák 2014; Slim 1995; Sunga et al. 2006; Weiss 2016). Additionally, working with local populations could be seen as a tacit endorsement of an ideology or political view (Joshi et al. 2008).

Organizational independence can be challenging to uphold. In complex emergencies with significant societal breakdowns, unscrupulous actors may take advantage of humanitarian organizations, restricting organizational activities in ways that advance their own agendas (Burkle Jr. et al. 2017; de Waal 2010). Unfortunately, when this occurs, it can also create a proximity effect that casts doubt upon the independence of other humanitarian organizations (Civaner et al. 2017; Rieffer-Flanagan 2009; Slim 1995). Funding sources can compromise independence by taking decision-making authority away from organizations if funding is conditional, e.g., specifying services offered or populations served (Clarinval and Biller-Andorno 2014; Harding-Pink 2004; MacCormack 2007; Slim 1997b).

A key threat to impartiality arose from external pressures to provide assistance not purely in accordance with need. These pressures could include extortionary negotiations demanding preferential treatment to gain access for combatants (Fennell 1998) and criminalization of providing aid to certain groups (Fouad et al. 2017). When threats to impartiality result in aid given to combatants (e.g., when threats of violence force health care workers to provide aid to combatants to prevent worse harm to others), organizations and workers may believe they are complicit in prolonging conflict (Fink 2007) and/or have violated their duty to be impartial (Geiger et al. 1989; Madhiwalla and Roy 2009). This can also result in restricting programs to more secure areas regardless of the needs of people living in insecure areas (Haver 2016).

Societal breakdowns, the loss of normal order, and punitive actions against humanitarian organizations severely limit their ability to fulfill their duty of humanity (Al-Moujahed et al. 2017; Fouad et al. 2017; Haver 2016; Poffley 2012). Violent threats, abduction, torture, and murder of humanitarian workers; blockade and theft of materials and supplies; and the elimination of access to or destruction of facilities also drastically impede humanitarian missions (Alderslade 1995; Blair 1996; Cobey et al. 1993; Fennell 1998; Fouad et al. 2017; Geiger et al. 1989; Haver 2016; Madhiwalla and Roy 2009; Redwood-Campbell et al. 2014). Efforts to avoid violence, such as concentrating operations in safe or comparatively secure areas, preclude access or attention to the most vulnerable and in need (Haver 2016). Facilities in conflict regions are often operating beyond their capacity and providers are unable to meet demands in high-volume crises or complex medical cases (Baskett 1994; Ben Shahar 1993; Domres et al. 2012; Leaning et al. 2011). Additionally, material scarcity and personnel shortages contribute to organizations’ limited efficacy of meeting the needs of beneficiaries (Hunt 2008).

Threats to the emergent humanitarian principle of solidarity were experienced in several ways. For example, because solidarity implies both suffering with and consulting community members, lack of coordination between organizations could lead to disorder, duplicative efforts, or blind spots in identifying community needs. This in turn can undermine organizations’ capacity for solidarity (MacCormack 2007). In addition, humanitarian workers themselves may struggle to feel they are in solidarity with local populations. Barriers to recognizing solidarity can also be exacerbated in violent situations and other complex emergencies where extreme circumstances can increase and reinforce humanitarian workers’ perceptions of “otherness” (e.g., because of cultural and language differences and/or economic disparities) of populations being served (Hunt et al. 2014).

Implications of the relationship between ethical obligations and humanitarian principles

Our review found multiple instances where ethical obligations and humanitarian principles intersect (Tables 3 and 4). The implications of this intersection are twofold. First, observing this connection brings additional clarity to the nature of the challenges humanitarian organizations may face when operating in conflict settings. For instance, seen through the intersection of ethics and humanitarian principles, the obligation to involve local communities in humanitarian response relates to fundamental ethical obligations of justice that involve fairness in decision-making, may help facilitate respect for local community norms, and could improve an organizations’ ability to deliver aid to communities in need, thereby meeting humanitarian obligations of humanity. At the same time, this must be done carefully, to preserve the humanitarian commitment to independence.

Second, the intersection between ethics and humanitarianism in conflict settings creates the potential for using ethical decision-making to support and improve humanitarian action. Workshops were conducted with Syrian humanitarian health workers in Gaziantep, Turkey and Amman, Jordan to review an earlier version of our literature review findings. Attendees supported both our original decision to categorize humanitarian principles and ethical obligations separately and the potential for having a better understanding of their intersection to improve organizational decision-making around ethical challenges. Frameworks for ethical decision-making have been proposed for humanitarian settings (Clarinval and Biller-Andorno 2014; Hunt 2008). These frameworks share a commitment to creating decision processes that help identify the ethical issues at stake in a particular situation and make better decisions around them. However, the ethical issues at stake may not always be clear to organizational stakeholders. Having investigated ethics obligations, humanitarian principles, and their inter-relationships, our review should help organizations better operationalize existing frameworks as they strive to maintain their ethical and humanitarian commitments and make better decisions. Still, we must acknowledge that whether these frameworks are both applicable and feasible in conflict settings remains an open question and should be the subject of future research.

Limitations

First, the search included only English language publications. Second, it is possible that not all the ethical and humanitarian challenges organizations experience are reported in the published literature. Third, our review did not include gray literature such as reports from think tanks, humanitarian organizations, and UN agencies, raising the possibility the other obligations and challenges have been identified. Fourth, we did not assess the quality of included publications. Finally, as a qualitative study, our findings involve subjectivity. It is possible that a different research team would produce different findings or come to different conclusions from these data. We believe that a broad initial search strategy and a structured method of qualitative content analysis helped address these limitations.

Conclusion

Conflict settings present substantial barriers to humanitarian health response efforts. By describing the range of challenges humanitarian organizations have faced in fulfilling their basic ethical obligations and humanitarian principles, this review can increase awareness of the nature and types of challenges organizations are likely to experience while trying to uphold their commitments in conflict settings. This can in turn aid organizational preparedness, including stimulating efforts to train and monitor humanitarian health workers and develop processes for addressing challenges in the field. In addition, it lays the foundation for future efforts aimed at tailoring existing frameworks for ethical decision-making and evaluating different methods of navigating these complex challenges.