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Keywords:

  • Development work;
  • Ethics;
  • Global health;
  • Health care professionals;
  • Humanitarian assistance;
  • Moral experience;
  • Non-governmental organizations

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Context and Intent of the Framework
  5. An Ethics Framework for Expatriate Clinicians in Humanitarian and Development Assistance
  6. Orientations of an Ethics of Engaged Presence
  7. Potential Impact of the Ethics of Engaged Presence Framework
  8. Conclusion
  9. Acknowledgments
  10. Footnotes
  11. Biographies

In this article, we present an ethics framework for health practice in humanitarian and development work: the ethics of engaged presence. The ethics of engaged presence framework aims to articulate in a systematic fashion approaches and orientations that support the engagement of expatriate health care professionals in ways that align with diverse obligations and responsibilities, and promote respectful and effective action and relationships. Drawn from a range of sources, the framework provides a vocabulary and narrative structure for examining the moral dimensions of providing development or humanitarian health assistance to individuals and communities, and working with and alongside local and international actors. The elements also help minimize or avoid certain miscalculations and harms. Emphasis is placed on the shared humanity of those who provide and those who receive assistance, acknowledgement of limits and risks related to the contributions of expatriate health care professionals, and the importance of providing skillful and relevant assistance. These elements articulate a moral posture for expatriate health care professionals that contributes to orienting the practice of clinicians in ways that reflect respect, humility, and solidarity. Health care professionals whose understanding and actions are consistent with the ethics of engaged presence will be oriented toward introspection and reflective practice and toward developing, sustaining and promoting collaborative partnerships.

You know the concept of ‘do no harm'? Therefore we always want to do that. When you don't know the culture you can have interventions that have consequences that you didn't know about: social harms or clinical harms (Nurse)

… you can't go work in these countries and expect that it will be the same, you know, that they use the same standard of care at this time in the world. It's just not remotely realistic or possible or doable and so you have to modify your expectations but I think but to what point? How do you do that? (Physician)

Our role is to talk about what we've seen and to advocate for those rural clinics or those kids lying on cement floors with meningitis, not getting the help they need … (Nurse)

And on the topic of power we need to really educate ourselves and our colleagues going to the field really about how much power we have: over priorities, over programs, over our staff … and the power that we hold over the beneficiaries. (Physician)

It was not that uncommon that someone arrived for the delivery and asked for the white girl even though I had much less experience than the midwife who is African. (Nurse)

You don't stop and you don't think about it. Also because you work six days a week you don't have much time to just reflect and when you come back you just realize it is just not normal to have to take decisions like this when you don't have the training for it. (Nurse)[1]

Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Context and Intent of the Framework
  5. An Ethics Framework for Expatriate Clinicians in Humanitarian and Development Assistance
  6. Orientations of an Ethics of Engaged Presence
  7. Potential Impact of the Ethics of Engaged Presence Framework
  8. Conclusion
  9. Acknowledgments
  10. Footnotes
  11. Biographies

Expatriate health care professionals participate in development and humanitarian projects in many locales around the world providing assistance in settings affected by disaster or war, or participating in efforts to support strained health systems in low resource settings.[2] Health care practice in these contexts requires expatriate clinicians to have the ability to adapt their clinical training and expertise for new realties where context and conditions may differ significantly from past experiences (see Table 1). Available human and material resources may be severely limited, while health needs of the population are elevated resulting in multiple and often very difficult allocation decisions at the local level.[3] These fields of health care practice also require clinicians to participate in and engage with new communities and populations. Local health practices and beliefs may be unfamiliar, and language and cultural barriers are common. Many aspects of social and political contexts, at local, regional and national levels remain ambiguous for expatriate clinicians. Humanitarian or development projects in some locales are also entangled with histories of colonial governance, including colonial medicine. Customary sources of professional support, such as a familiar set of colleagues from a range of disciplines and specialties, established professional consensus, and institutional resources such as ethics committees, are often unavailable in local projects. Many individuals are also separated from friends and family, and may have few social connections and sources of emotional and psychological support outside their own team. Finally, health care professionals must adapt to, and work within, the particular structures, policies and organizational culture of a non-governmental organization (NGO).

Table 1. Taken together, these features define the distinctive character of health care practice for expatriate clinicians from high resource healthcare systems during humanitarian assistance and development work
  • Relocation to another country
  • Material and health resources are scarcer
  • Material and health needs are greater
  • Population health considerations are prominent
  • Social /political contexts experienced as ambiguous
  • Clinicians lack familiar resources and supports
  • Accountability and governance often less certain
  • Roles and responsibilities often less defined
  • In some settings, colonial history an important background feature
  • Expatriate clinicians work within structures and mandates of NGOs

Hugo Slim highlights the challenging nature of this field of practice when he cites an earlier tongue-in-cheek description by Susan George of the professional requirements for the humanitarian practitioner.[4] According to George, humanitarian workers should have ‘graduate degrees in social anthropology, geography, economics, a dozen or so difficult and unrelated languages, medicine and business administration … competence in agronomy, hydrology, practical nursing, accounting, psychology, automotive mechanics and civil engineering. In addition, they must learn to give a credible imitation of saintliness …’[5] For Slim, the humanitarian worker must also be ‘something of a moral philosopher’.[6] Slim's addition emphasizes the complexity and uncertainty associated with the political and moral dimensions of many settings of humanitarian aid, and the reality that good intentions are no guarantee of good outcomes, and are not uncommonly associated with harm to the people they intend to benefit.[7] For example, the presence of humanitarian actors might contribute to prolonging conflict if armed factions steal material resources of NGOs, tax humanitarian agencies, or if humanitarian medical projects are used as an opportunity to divert government funding from healthcare to the military.[8] In other settings, restrictions imposed on humanitarian assistance can result in harm to the population such as when governments dictate that aid be distributed in a manner that promotes the internal displacement of civilians.[9] While there has been significant discussion of ethical questions associated with humanitarian assistance and development aid, this analysis has predominantly been focused at the level of organizations and governments. Challenging ethical issues also arise at the local project level and in clinical encounters. Recently, increased discussion of ethical issues for global health work has taken place. Evaluation of ethical issues for short-term medical missions has been carried out,[10] as well as discussion of ethics for clinical electives undertaken by Western medical students in low and middle-income countries.[11] In addition, there is a growing field of inquiry related to ethics of health care practice in humanitarian and development work.[12]

We have conducted three qualitative studies examining ethical issues in development assistance and humanitarian work.[13] These studies illuminate various facets of how health care professionals experience and understand the moral dimensions of their participation in global health projects. Collectively, 45 clinicians have been interviewed. Schwarrtz et al examined ethical dilemmas experienced by Canadian health care professionals in these settings and identified four main sources of ethical challenges.[14] Ethical challenges arise due to scarce resources and the need to allocate them in settings of elevated health needs; practicing in settings that are strongly influenced by inequalities associated with historical, political, social and commercial structures; aid agency policies and agendas that organize and direct the provision of care to local populations; and perceived norms around health professionals’ roles and interactions. As illustrated by this research, these ethical challenges have an impact on the sense of professional and personal identity of health care professionals.

The moral dimensions of these fields of healthcare practice extend beyond specific ethical dilemmas or problems. In a second study, Hunt identified key components of moral experience for health care professionals in humanitarian work: clarifying and examining motivations and expectations, the relationality of humanitarian work, addressing steep imbalances of power, acknowledging and confronting the limited horizon of what is possible in a given situation, and the ways that organizational structures shape everyday moral experience.[15] This study also illustrates the all-encompassing nature of humanitarian work for expatriate clinicians: boundaries between work and non-work tend to dissolve, and relationships within the team often become critical sources of support and primary reference points for individual clinicians.

Examination of ethical questions in humanitarian health care practice can draw on existing theory in several domains, including clinical and professional ethics (which are the bodies of knowledge that most expatriate clinicians have been trained in), human rights and international humanitarian law, as well as the burgeoning field of public health ethics. Elsewhere, we have examined the potential contributions of a range of ethical theories and ethics resources for health care professionals in humanitarian settings.[16] In this paper, we begin from the recognition that further ethical analysis addressing this field of practice is needed.[17] Existing articulations of ethics for healthcare practice, including professional codes of ethics, are often insufficiently adapted for the context of healthcare practice in development and humanitarian work or the range of issues experienced by clinicians.[18] The transnational and transcultural nature of this work shapes ethical issues of practice in these settings. The approaches of western clinical ethics – including a dominant focus on the individual, and conceptions of personal autonomy – require balancing with other contributions and perspectives.[19]

Our purpose in this paper is to contribute to the ongoing discussion of ethics for health professionals in global health work, with particular attention to contexts of humanitarian and development assistance. We propose a framework that draws together approaches and orientations that support the engagement of expatriate clinicians in ways that are aligned with their obligations and that can contribute to the promotion of respectful and effective action and relationships in humanitarian and development work, and reflect respect, humility, and solidarity.

Context and Intent of the Framework

  1. Top of page
  2. Abstract
  3. Introduction
  4. Context and Intent of the Framework
  5. An Ethics Framework for Expatriate Clinicians in Humanitarian and Development Assistance
  6. Orientations of an Ethics of Engaged Presence
  7. Potential Impact of the Ethics of Engaged Presence Framework
  8. Conclusion
  9. Acknowledgments
  10. Footnotes
  11. Biographies

We draw from our empirical research to inform and test the normative account that we develop. The framework is also shaped by the field experiences of the first author who is a physiotherapist and has worked in several development-oriented projects, and the fourth author who is a physician who has participated in a range of development and relief projects. Finally, the account that we develop here is linked to two theoretical sources: a conception of moral experience and a virtue ethics approach. The framework is inspired by an understanding of moral experience that extends beyond a focus on dilemmas or problems, and encompasses broad contours of what individuals identify as morally relevant in a given context.[20] Moral experience encompasses ‘a person's sense that values that he or she deem important are being realised or thwarted in everyday life. This includes a person's interpretations of a lived encounter, or a set of lived encounters, that fall on spectrums of right-wrong, good-bad or just-unjust’.[21] Our account is also inspired by virtue ethics, with its focus on moral character in distinction to normative approaches that primarily emphasize rules or consequences of actions.[22]

The proposed framework is intended to have relevance in diverse aspects of expatriate clinicians’ participation in global health work, and is not limited to the resolution of situations that are identified as quandaries or conflicts. It is not intended to exclusively address clinical decision-making or provide explicit answers to traditionally preoccupying topics of medical ethics (e.g. consent, confidentiality, and so forth). Rather, it describes an understanding of responsibilities and orientations for expatriate clinicians that precedes and shapes the response to these and other practical issues. The framework is an articulation of approaches and orientations that support ethically-sound, contextually-responsive humanitarian health work. As such it implicates attitudes, practices and relationships of expatriate health care professionals and relates to a broad array of moral experience for expatriate health care professionals and how they understand the purpose and scope of their involvement in global health activities.

An Ethics Framework for Expatriate Clinicians in Humanitarian and Development Assistance

  1. Top of page
  2. Abstract
  3. Introduction
  4. Context and Intent of the Framework
  5. An Ethics Framework for Expatriate Clinicians in Humanitarian and Development Assistance
  6. Orientations of an Ethics of Engaged Presence
  7. Potential Impact of the Ethics of Engaged Presence Framework
  8. Conclusion
  9. Acknowledgments
  10. Footnotes
  11. Biographies

Expatriate health care professionals who take part in development and humanitarian work engage in a particular type of action. Their commitment to global health is manifested through embodied presence; while in the field they are proximate, at hand, and engaged with individuals and communities in situations of need and deprivation. A distinctive feature of this work is that it involves relocation to another country to provide practical assistance to communities with elevated, and possibly acute, needs. Being present with the local population in times of need or crisis is a fundamental aspect of health care practice in these settings that extends beyond the skillful practice of professional tasks and duties. In the account that we develop in this article, the presence of expatriate health care professionals and the distances traveled (geographic, cultural and professional) to arrive at the locales where they provide assistance are starting points for articulating a normative framework to support their activities in humanitarian assistance and development work: an ethics of engaged presence.

There are three core facets of the framework, which we describe as elements. Together these elements capture the main content of the ethics of engaged presence framework: recognition of the shared humanity of those in need of assistance and those in positions to provide it (in the context of global disparities); acknowledgement of limits to one's ability to assist and risks associated with helping; and provision of competent, practical assistance.[23] The three elements are not fully distinct – there is an interrelationship amongst them. These elements articulate, in a systematic way, a moral posture for expatriate health care professionals. The elements contribute to orienting the practice of clinicians in ways that reflect respect, humility, and solidarity. The elements also help minimize or avoid certain miscalculations and harms. We will examine these elements of an ethics of engaged presence in turn, before describing the two orientations associated with the framework.

Recognizing shared humanity (in the context of global disparity)

… to be living in a nice house in a gated community in rural Africa where you step outside the door and there are people living in huts and what not. And every morning the nice white vehicle would come and pick us up and bring us to the local district hospital. That to me also, that to me was a huge, a huge ethical challenge. …[24] (Physician)

The first element of an ethics of engaged presence is recognition of the shared humanity and vulnerability that exists in health care practice in global health settings.[25] Shared humanity is a reality in all healthcare contexts. It is emphasized here because of the possibility in settings of crisis or deprivation for it to be obscured due to steep circumstantial inequalities and the so-called ‘dehumanizing effects’ of catastrophe. In addition, crisis and acute need can reinforce the otherness of those in need in the eyes of those providing assistance.[26] This perception may also be associated with lingering colonial narratives that can operate in discourses around aid and relief[27] and some strategies to raise funds and awareness of aid agencies but which reinforce the image of aid recipients as victims.[28] Acknowledging, and bringing to the fore, the shared humanity and vulnerability of those who provide and those who receive assistance stands against a view of expatriate clinicians who arrive from away as rescuers or saviours. This acknowledgement of shared humanity is not meant to ignore or dismiss the inherent imbalance of power in these situations.[29] Quite the opposite: this element of an ethics of engaged presence provides a critical perspective to identify and address ways that power imbalances and ‘othering’ discourses and practices could be challenged or diminished, but which have yet to be identified or acted upon. It may well be the case that clinicians feel they need to adopt a certain professional distance to cope with situations of emergency or widespread need. However, this professional distance should not overshadow or hide the humanity of those who require assistance. Expatriate clinicians have considerable power in arriving from another country to provide assistance. Acknowledging imbalances of power and seeking to address them where possible will help clinicians to genuinely attend to the needs and suffering of local persons as moral equals,[30] and to relate to local health care professionals and other officials as colleagues and partners in seeking to meet local needs.

This emphasis on the shared humanity of expatriates, national staff, local officials, and individuals who receive assistance, is also linked to the principle of solidarity. Solidarity is usually understood to arise when people stand together to respond to a shared crisis within a group,[31] however, it may reasonably be extended to involve exploration and identification of what is common and shared among and between individuals and communities including vulnerability to situations of crisis.[32] Solidarity has been advocated as a key principle for global health ethics.[33] It is linked to notions of equality, and entails working for the interests of others, and a commitment to ‘stand together’. In this way, the principle of solidarity underpins acknowledgement of the shared humanity of those who give and those who receive assistance, and supports the work of expatriate health professionals who are present amidst crisis or need in order to provide assistance and support.[34]

Acknowledging limits and risks

We are there as guests in many ways and there needs to be a sense of, ‘I don't know everything’ because none of us do when we are in another country. (Nurse)

The second component of an ethics of engaged presence is acknowledgement of the limits of what can be contributed both individually and collectively (as a local team, in a particular project, or as the larger humanitarian community), as well as recognition of the potential for unintended harmful consequences.[35] This element of the ethics of engaged presence is linked to the virtue of humility, and realism in the evaluation of one's ability to assist. It also includes acknowledging the limits of one's understanding of the local social, cultural and political context. An appreciation of these limits provides a more realistic portrait of expatriate clinicians’ roles and the possibility of unanticipated harm.

While seeking to expand care and services at the local level, acknowledging limits and risks will also lead health care professionals to recognize constraints and orient their approach in consequence.[36] Frank appraisal of one's role and ability to assist will have broad influence on clinicians in development and humanitarian settings. Expatriate clinicians who acknowledge limits to their ability to understand the local situation, and their ability to address the health and other needs of the population, are more likely to ask for assistance and seek guidance from a range of sources. Recognizing the limits of what is known to be effective might also be associated with openness to evaluate and test interventions, as well as to innovate, so as to contribute to expanding the evidence base that supports global health interventions.[37]

Finally, this element of the ethics of engaged presence includes recognition of and grappling with the uncomfortable reality that, as described above, humanitarian interventions and the actions of expatriates sometimes result in unintended harmful consequences.[38] These harms may occur at a broad level, such as the manipulation of aid by warring parties. Other unintended harms occur in local projects, for example when expatriates transgress local customs and values through a lack of awareness of cultural norms.[39] A range of harms can be avoided through training, technical innovation, improved coordination and better programming, however other forms of harm may be unavoidable for local teams such as where existing disparities or injustices cannot be quickly or easily redressed.[40] A clinician who is conscious of the potential for harmful consequences, however, will be alert to this possibility and better prepared to anticipate and avoid such outcomes, or to mitigate harm when it does occur.

‘First, be prepared’[41] : Providing competent, practical assistance

I was going, I was a medical person going into a medical facility. I wish I had been more prepared about what I was going to be seeing and doing. (Nurse Practitioner)[42]

The final element of an ethics of engaged presence is perhaps the most obvious. Expatriate health care professionals who work with aid agencies in settings of heightened need, disaster, or armed conflict are expected to contribute to addressing and alleviating local health needs. Thus the provision of skillful assistance toward meeting relevant local needs is a key element of an ethics of engaged presence. The training and background of expatriate clinicians may only partly map onto the skills and knowledge needed in particular projects. Expatriate clinicians can expand the area of overlap by embarking on training activities and choosing projects for which their prior experience provides better preparation, while seeking to effectively transpose their existing skills and understanding to new contexts.

A health care professional who cannot perform the duties required of her or him in a local project will be unable to provide expected or needed assistance. To be able to provide such assistance, expatriate clinicians require both a set of relevant skills and knowledge, and the ability to make necessary adaptations to apply them in the local project context. ‘On the job’ training will inevitably be part of this process and the learning curve is often steep. However, health care professionals come with the goal, and are received with the expectation, that they will bring skills to provide practical help to individuals and populations in need. This is a crucial aspect of this work.

Clinicians who arrive in the field under-prepared and who are unable to adapt their skills and knowledge will have limited opportunities to contribute to addressing local needs. They may also experience frustration and distress if they are unable to provide the care and assistance that is needed in the local setting – a situation that is much more likely for those who are less well prepared. Inadequately prepared clinicians will also be a burden on local and expatriate colleagues if they require extra support and supervision. This reality further suggests that some humanitarian aid projects – especially where the situation is acute – are not suitable for trainees or even some newly licensed clinicians.

The responsibility for ensuring a sufficient level of preparation for newly arrived clinicians is shared between NGOs (who vet clinicians for their skills and training, and who provide pre-departure training) and health care professionals themselves (who can seek out formal and informal experiences that contribute to their readiness, and select projects that better match their skills, language abilities and background). In this light, organizations have a duty to prepare staff, and clinicians a duty to be prepared. Paradoxically, part of preparing clinicians for this work is also preparing them for the reality that there will be situations for which they are not prepared, and the need to adapt their knowledge for new contexts, and to learn from others who are more skilled, including local clinicians.

Orientations of an Ethics of Engaged Presence

  1. Top of page
  2. Abstract
  3. Introduction
  4. Context and Intent of the Framework
  5. An Ethics Framework for Expatriate Clinicians in Humanitarian and Development Assistance
  6. Orientations of an Ethics of Engaged Presence
  7. Potential Impact of the Ethics of Engaged Presence Framework
  8. Conclusion
  9. Acknowledgments
  10. Footnotes
  11. Biographies

Two sets of orientations are also part of the framework. By describing these components of an ethics of engaged presence as orientations, we mean that these are directions and approaches that will support practitioners committed to the three elements of the framework. The elements of the ethics of engaged presence orient health care professionals toward reflective practice, and to developing, promoting and sustaining partnership and collaboration where possible. The orientations thus provide direction for the relational dimensions of aid work, including asymmetries and connections associated with relationships between expatriate clinicians and other actors. In contrast, self-focus, a lack of critical reflection, or consistently acting in isolation from others, detract from respectful and productive relationships, and work against the provision of high-quality aid and care. These orientations have circumscribed spheres of application; health care professionals are encouraged to enact reflective practice and promote collaboration, but they will also recognize contexts when doing so is less feasible.

Introspection and reflective practice

And as westerners it's very hard to get outside of our own confident opinion, viewpoint or paradigm. Anything that helps us to be able to see the rationale or the assumptions or the worldview behind why things seem strange to us, why they do things differently or see things differently. I'm not good at that but I know that's what I should be doing. (Physician)

The ethics of engaged presence support and are supported by reflective practice. Clinicians who participate in humanitarian or development projects benefit from critical examination of their assumptions and actions in the context of their international work, as well as their motivations for participating in this work, and the congruence of their motivations with those of the local project and the NGO. Such an approach also supports clinicians to consider how they, and the NGOs for which they work, are situated within transnational social, political and economic processes that shape their local contexts of action. An orientation toward reflexivity is especially important given the trans-national, inter-cultural nature of these fields of healthcare practice, as there is less that expatriate clinicians can take for granted in these contexts.[43] Tacit knowledge regarding a range of contextual issues, including cultural and social norms, functioning of the healthcare system, professional expectations and political realities, will be put into question. An introspective orientation supports clinicians to be alert to the ways that their assumptions, and those of other actors, shape perceptions of a given situation, as well as recognizing the limits of what they can achieve and the potential for harm to result from well intentioned actions.

Introspection and reflexivity have obvious limits. Protracted introspection could lead to stasis or even something like paralysis. Health care professionals, especially those working in more acute situations, must make decisions and must act, sometimes with little opportunity to deliberate or discuss options. The orientation toward introspection and reflective practice should be understood in this light. Careful consideration and reflection are key components of the process of evaluating the moral dimensions of particular situations so that well considered and ethically defensible actions can be identified and enacted.

Collaboration and partnership

I think that you get your answers in the population. You can take the local workers that you work with – nurses, translators – or if you have a partner, … a local NGO for instance, so our local counterparts are the ones who give us, who are the most valuable for these kind of answers. And I believe that you just can't do a project without consulting some kind of local authority or local counterpart. (Physician)

Expatriate health care professionals and international NGOs may have a tendency to, on occasion, ‘go it alone’. In certain situations, particularly during acute crises, it may appear more efficient to provide assistance separate from local actors, or to rely exclusively on external expertise and approaches. Humanitarian agencies may also fail to communicate effectively with each other or coordinate activities.[44] However, the ethics of engaged presence support an underlying orientation to build collaborative relationships whenever possible. Doing so will contribute to diminishing imbalances of power that are prevalent in such settings. It may also help avoid replicating (and being perceived as replicating) colonial patterns. Efforts by international NGOs, local health workers and local agencies to work collaboratively will lead to less redundancy between projects, and more trusting and productive relationships. One aspect of this collaboration might be greater appreciation by expatriate clinicians and organizations for the knowledge, efforts and successes of local actors,[45] at both organizational and individual levels. An orientation toward collaboration will be supported by identification of common cause and common goals with individuals and groups, and demonstrates solidarity and recognition of shared humanity.

Collaboration and partnership building hold differing possibilities in different settings. The types of grass-root, community level partnerships that can emerge within a development-oriented project are quite different than more hastily drawn together collaborations in an emergency response following disaster. In situations of acute crisis, opportunities for dialogue and consultation may be limited. The need for a rapid response in these settings will preclude a protracted process of discussion and evaluation. However, interventions should still be developed in partnership with local representatives, and coordination amongst different actors is essential.[46] Thus in both development and humanitarian contexts collaboration remains an important goal. Collaboration between aid agencies, including local project teams, supports more efficient and effective assistance by diminishing redundancy and fostering the interlinking of projects. As practitioners seek to establish collaborative partnerships, organizational structures and systems as well as organizational culture must provide space for such initiatives.

The orientations towards reflexivity and collaboration require flexibility as their application varies between contexts. Where the orientations are not followed, compelling rationales should exist.

Potential Impact of the Ethics of Engaged Presence Framework

  1. Top of page
  2. Abstract
  3. Introduction
  4. Context and Intent of the Framework
  5. An Ethics Framework for Expatriate Clinicians in Humanitarian and Development Assistance
  6. Orientations of an Ethics of Engaged Presence
  7. Potential Impact of the Ethics of Engaged Presence Framework
  8. Conclusion
  9. Acknowledgments
  10. Footnotes
  11. Biographies

The ethics of engaged presence framework is an articulation of a moral posture for expatriate clinicians in humanitarian and development work that is congruent with respectful and effective action and relationships. We believe that acting in ways that are consistent with the ethics of engaged presence has a range of effects. The elements of the framework will support partnerships between various local and international actors providing assistance at the local level, and contribute to reducing the weight of paternalistic approaches in aid programming. Enhanced collaboration can also yield more efficient programs and interventions. This approach will thus promote more effective use of resources.

Respect is manifest in multiple ways in the ethics of engaged presence. There is recognition by expatriate workers that their insights into local realities are always limited. Expatriate clinicians are supported to acknowledge that their way is neither the only nor always the best way to address a particular issue. This should lead to greater openness to examine alternative approaches and receptivity toward local perspectives and concerns. Expatriate health care professionals will also be careful to guard against being overly eager to enact change or implement new programs without consulting and working with local staff members, officials or clinicians. For these reasons, the ethics of engaged presence can help to guard against some situations when outside assistance results in harm for local communities despite the well-intentioned actions of expatriate workers. This approach can also contribute to the sustainability of interventions. Where local participation and relevance have been addressed throughout the course of the project the impacts of the project are more likely to be sustained. In addition, the ethics of engaged presence demonstrate respect for individuals and communities in ways that, in settings of disaster or conflict, might ease the transition back to independence from outside assistance once the crisis has receded. The focus on collaboration and respect is also consistent with codes and charters for humanitarian practitioners.[47]

The framework itself might be used in several ways. First, it can have a pedagogic use and be provided as part of a pre-departure package to clinicians. Ideally, the framework and its content would be discussed as part of pre-departure sessions and could foster reflection and deliberation about moral dimensions of aid work. The framework could also be used within NGOs and local teams as a structure for evaluating approaches and actions within particular projects.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Context and Intent of the Framework
  5. An Ethics Framework for Expatriate Clinicians in Humanitarian and Development Assistance
  6. Orientations of an Ethics of Engaged Presence
  7. Potential Impact of the Ethics of Engaged Presence Framework
  8. Conclusion
  9. Acknowledgments
  10. Footnotes
  11. Biographies

In this article we have drawn on a range of sources to develop a framework for expatriate health care professionals in humanitarian and development settings that articulates elements and orientations that foster respectful and effective action and relationships in development and humanitarian work. The ethics of engaged presence is grounded in a commitment to be present with communities and individuals in need of assistance due to disaster, armed conflict, or extreme poverty. The framework emphasizes the shared humanity of those who provide and those who receive assistance, calls for acknowledgement of limits and risks related to the participation of expatriate clinicians in global health settings, and underscores the importance of preparation for and provision of skillful and relevant assistance. The ethics of engaged presence also supports two sets of orientations. Clinicians whose understanding and actions are consistent with an ethics of engaged presence will be oriented toward introspection and reflective practice. They will also be oriented toward developing, sustaining and promoting collaborative partnerships whenever feasible.

The scope of the ethics of engaged presence is broad: the full spectrum of relational and professional activities of expatriate health care professionals. Our articulation of an ethics of engaged presence focuses on clinicians who travel from one country to another to provide assistance in settings of war, disaster or deprivation, however aspects of this framework may also be relevant for others involved in global health activities including other professional groups, trainees and national staff, and clinicians on short-term missions.

The ethics of engaged presence provides a vocabulary and structure for examining key elements and orientations associated with the moral dimensions of providing assistance as expatriate clinicians to individuals and communities, and working with and alongside a range of local and international actors.

Acknowledgments

  1. Top of page
  2. Abstract
  3. Introduction
  4. Context and Intent of the Framework
  5. An Ethics Framework for Expatriate Clinicians in Humanitarian and Development Assistance
  6. Orientations of an Ethics of Engaged Presence
  7. Potential Impact of the Ethics of Engaged Presence Framework
  8. Conclusion
  9. Acknowledgments
  10. Footnotes
  11. Biographies

We wish to thank the respondents of the research studies discussed in this paper, Hillel Braude and James Anderson for helpful comments on an earlier version of the manuscript, the members of our broader research team (Naomi Adelson, Sonya de Laat, Jennifer Ranford, and Lynda Redwood-Campbell) for their contributions to our thinking around these issues, and to the anonymous reviewers for Developing World Bioethics. The ideas presented in this paper also benefited from feedback received from participants at the 2010 Feminist Approaches to Bioethics conference in Singapore, the 2010 AIRMEC symposium in Paris, France, and the 2010 CREUM/UofT colloquium in Montreal, Canada. Christina Sinding is supported by a New Investigator Award from the Canadian Institutes of Health Research, and Lisa Schwartz by a private endowed chair. The research presented in this article was funded by a grant from the Canadian Institutes of Health Research (200703EOG).

Footnotes

  1. Top of page
  2. Abstract
  3. Introduction
  4. Context and Intent of the Framework
  5. An Ethics Framework for Expatriate Clinicians in Humanitarian and Development Assistance
  6. Orientations of an Ethics of Engaged Presence
  7. Potential Impact of the Ethics of Engaged Presence Framework
  8. Conclusion
  9. Acknowledgments
  10. Footnotes
  11. Biographies
  • 1
    These verbatim quotes were collected during interviews with Canadian health care professionals discussing ethical issues encountered during their participation in humanitarian assistance or development work (M.R. Hunt. Ethics beyond borders: How health professionals experience ethics in humanitarian assistance and development work. Dev World Bioeth 2008; 8: 5969. M.R. Hunt. Moral experience of Canadian health care professionals in humanitarian work. Prehosp Disaster Med 2009; 24: 518524. L. Schwartz, C. Sinding, M. Hunt, L. Elit, L. Redwood-Campbell, N. Adelson, L. Luther, J. Ranford & S. DeLaat. Ethics in humanitarian aid work: learning from the narratives of humanitarian health workers. AJOB Prim Res 2010; 1: 4554).We include these quotes here to illustrate the range of ethical challenges arising in these fields of practice.
  • 2
    We use the term ‘expatriate’ to describe staff of international organizations who come from other countries to participate in aid projects, and is contrasted with ‘local’ or ‘national’ staff members. This usage is consistent with how such individuals are referred to within the humanitarian and development fields. Expatriates come from many different nations to participate in this work, however our focus here is particularly on those who come from high resource healthcare systems.
  • 3
    A. de Waal. The humanitarians’ tragedy: Escapable and inescapable cruelties. Disasters 2010; 34: S130S137.
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    L. Schwartz, C. Sinding, M. Hunt, L. Elit, L. Redwood-Campbell, N. Adelson, L. Luther, J. Ranford & S. DeLaat. op. cit. note 1.
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    M.R. Hunt 2009. Op. cit. note 1.
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  • 24
    Schwartz et al, 2010, p. 48, op. cit. note 1. Verbatim quotes from research participants are included to illustrate each of the elements and orientations.
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    Direct Link:
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    Op. cit. note 3.
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    M.R. Hunt, 2009, p. 522, op. cit. note 1.
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    For example, in responding to a disaster the actions of local rescuers may be overshadowed and obscured by attention given to international teams. S.L. Kasfir. Narrating Trauma as Modernity: Kenyan Artists and the American Embassy Bombing. African Arts 2005; 38: 6677.
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Biographies

  1. Top of page
  2. Abstract
  3. Introduction
  4. Context and Intent of the Framework
  5. An Ethics Framework for Expatriate Clinicians in Humanitarian and Development Assistance
  6. Orientations of an Ethics of Engaged Presence
  7. Potential Impact of the Ethics of Engaged Presence Framework
  8. Conclusion
  9. Acknowledgments
  10. Footnotes
  11. Biographies
  • Matthew R. Hunt is an Assistant Professor in the School of Physical and Occupational Therapy at McGill University, and a Researcher at the Centre for Interdisciplinary Research in Rehabilitation. He is co-Principal Investigator of a research programme on humanitarian healthcare and ethics funded by the Canadian Institutes of Health Research (humanitarianhealthethics.net). Previously he has worked as a physiotherapist in North Africa and the Balkans.

  • Lisa Schwartz is the Arnold L. Johnson Chair in Health Care Ethics at McMaster University. She is also the Director of the interdisciplinary PhD in Health Policy. Dr Schwartz is lead and co-investigator on a programme of CIHR funded research related to Humanitarian Healthcare Ethics. Her PhD is in Philosophy which she received at the University of Glasgow. She is Associate Professor in the department of Clinical Epidemiology & Biostatistics and co-associate Director of the Centre for Health Economics and Policy Analysis (CHEPA) in the Faculty of Health Sciences.

  • Christina Sinding is an Associate Professor at McMaster University, Hamilton, Ontario, Canada, jointly appointed to the School of Social Work and the Department of Health, Aging and Society. Her research explores what lay people ask and expect from health professionals, and what professionals are inclined and able to offer, in the context of public sector restructuring and changing ideas about care.

  • Laurie Elit is a professor in the Department of Obstetrics and Gynecology at McMaster University and a gynecologic oncologist at the Juravinski Cancer Centre, Hamilton, Canada. She has a long history of working in various developing world settings as a clinician, educator and researcher.