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19 Jul 18 17 Aug 18

Book excerpt: MSF and the ethical challenges of humanitarian action

As a humanitarian medical organization, Doctors Without Borders/Médecins Sans Frontières (MSF) intervenes in places around the world affected by conflict and crisis. Although we are guided by humanitarian principles, our medical teams are often confronted with complicated dilemmas. In a chapter from a new book called Humanitarian Action and Ethics (Zed Books), current and former MSF field workers consider some of the ethical challenges that form an inevitable part of MSF's medical humanitarian action, and how the organization can better enable our staff and front-line field workers to address them.

From the Summer 2018 issue of Dispatches, the MSF Canada magazine

The following has been excerpted from “Humanitarian ethics in Médecins Sans Frontières/Doctors Without Borders: Discussing dilemmas and mitigating moral distress” by Rachel Kiddell-Monroe, Carol Devine, John Pringle, Sidney Wong and Philippe Calain, which appears in the book Humanitarian Action and Ethics. © Zed Books 2018.

Ethical issues are pervasive in humanitarian action. Médecins SansFrontières/Doctors Without Borders (MSF) has faced such issues since the organisation was founded. These ethical issues are not a theoretical pastime for MSF: they have a real and lasting impact on the people we try to assist, as well as on our project and headquarters staff. Yet, medical and non-medical humanitarian aid workers find themselves in unfamiliar contexts, often vulnerable and isolated in the process of making difficult – and sometimes what feel like impossible – decision sabout which course of action to take.

Brought to a head by experiences during the West Africa Ebola crisis, in 2016, MSF’s International General Assembly (IGA), the organization’s highest governance body, acknowledged the ‘profound moral challenges inherent in humanitarian action’. The IGA resolved to take concrete steps to address ethical dilemmas more openly, more effectively, and with more purpose and accountability.

Today, MSF is trying to consciously promote and create space for ethical dialogue, and to develop tools intended to reduce moral distress among project staff. By passing this deliberative motion, MSF seeks to ensure more coherent and tangible mechanisms for the ethical analysis of challenges and dilemmas, as well as practical support for all of our staff, from recruitment to post-mission. By creating spaces for ethical discussions, the intention is to implement a more systematic approach to humanitarian ethics in MSF by understanding how to identify ethical dilemmas and challenges, by making choices and decisions that respect our core humanitarian principles, and by ensuring that we put our patients first.

MSF Case Study  – Barriers and Moral Distress for Humanitarians Denied Access: Paul’s Story

Paul is an experienced emergency medical practitioner with MSF.7He has completed multiple missions in conflict zones and unstable regions where mortality and morbidity is invariably high among affected populations. While sharing the moral dilemmas he faced, Paul does not wish to disclose details of the particular country or context due to the sensitive political situation: ‘We have to protect the people we are trying to assist and our field teams.’

He and his team were blocked from reaching thousands of people with both suspected and reported humanitarian needs. The government cited security concerns, yet the team was concerned for this large population, residing in an ‘apocalyptic’ place with little humanitarian assistance. ‘As health care workers, we had an amazing team of emergency trained national medical staff, we had all the resources: we just didn’t have access. That’s morally distressing.’

In this ‘very political situation’, Paul’s team tried daily to gain access to this particularly vulnerable population. They had conversations around access, strategizing, and negotiating with the government. However, it should be noted that MSF also had teams working in other parts of the country and did not want to jeopardize those projects. On this, Paul noted that, ‘We have to maintain neutrality and when we do advocate or speak out, we have to do it carefully, like a delicate political dance. We were always hopeful, thinking maybe next week we’ll get access.’

An ethical dilemma and moral distress

One incident raised an ethical dilemma and exacerbated Paul and team’s moral distress. The team heard reports of a child whose situation was likely a medical emergency. The team received an image of the child but they were unable to fully assess the child’s medical situation without a clinical assessment. The government gave MSF permission to provide medical care to this child, and to proceed with a medical evacuation if necessary. While Paul wanted to go and assess the child, another emergency medical professional on the team thought that an attempt to reach and evacuate one patient would jeopardize MSF’s impartial stance.

Nevertheless, Paul felt that ‘we should be able to evacuate the child if necessary and use our advocacy position to say, “This is what we’re doing, there are other people there in need, we need access to the population.” We could use this example as leverage.’ The dilemma faced by the team ultimately related to the need to make a choice between assessing and potentially saving the life of one child, and on the other hand maintaining the security of the mission and the ability to continue working in the same context, and the desire to eventually access the whole population. ‘It wasn’t a logistical question it was more about the higher-level strategy. Yes, we could go there and see this child: we have a driver, vehicle, medicine and equipment, we have an emergency nurse and doctor.’ This assertion was contrasted with a strategy of, ‘Let’s be careful now, we want good relations with the country we don’t want to push too much.’

Initially, Paul was conflicted, ‘It’s hard not to have an emotional response and think this is what we are here to do.’ Gaining access became an obsession for the team, as they remained in the same plac efor many weeks, with little else to do but wait. ‘Every day we were asking, How many water trucks got through today? What’s happening with the food delivery? It wasn’t allowed this week.’ Eventually Paul was able to resolve this tension, with support from a colleague. ‘I came around eventually. We had really good conversations about the situation. I was with someone who was so grounded and very experienced. I trusted and respected her. She helped me understand it wouldn’t be the right decision to try to help only one person. There was no perfect decision but at the same time I think about other missions where we compromise our values to a certain extent to still be allowed to have some humanitarian and medical presence. Sometimes that risk is worth the benefit to provide medical care.’

Paul’s team were ultimately unable to secure access during his mission. They hoped that the child recovered because they did not hear about her again. ‘In the end, the process of “do we go or not” became important. If the child died because we didn’t go then we’d likely look back wondering if we should have done something differently.’ Reflecting on his mission Paul later contemplated,

Were we right to try to get to the people? Yes. Should we have continued to have advocated for access? Absolutely. Being there without doing any medical activity, we were still advocating through hour humanitarian presence and pushing for access to medical care. I think we did the best job possible but we were limited by the politics. I think many people can’t appreciate that we have these barriers. I’ve been in other situations where we are able to treat patients but it’s the government’s decision to allow us access, and that access can be taken away anytime. Sometimes we’re very limited in what we can speak about.

Paul’s case has contextual specificity, yet at the same time, the challenges he describes echo other dilemmas that MSF has faced, and will undoubtedly face again. On reflection, he found it invaluable that his team was able to openly voice and discuss the dilemmas they faced, and that all members of the team were able to participate in decision making processes. The team was able to generate open dialogue related to ethical questions, but also to seek advice from staff at headquarters who had experienced ethically complex situations, but who also shared a concern for macro-level issues. Creating this shared space within the team ultimately reduced Paul’s experience of moral distress: ‘I was blessed to have a small, inclusive team where we could all speak openly.’

On reflection, Paul recognized that, ‘There are these moral dilemmas in the field, and it’s easy to look back and question what you did, whether your decisions were right. These dilemmas are so complicated and the decisions are weighted. It’s layered. I think it’s so important to have these conversations in the field, to have buy-in from the team on hard decisions. Lastly, I think the moral distress not only comes from dealing with circumstances in the field but also the somewhat isolating aftermath. Due to the often-delicate political nature of our work, there are scenarios we are unable to really talk about when we reintegrate into our lives back home. MSF of course has opportunities to debrief and provides counselling support post-mission but this highlights for me the link between moral distress and mental health support, which is a major issue for humanitarian ethics.’


Ethical debates exist at the core of MSF. Ethical dilemmas and challenges touch on our identity and our interpretation and application of the humanitarian principles. The two interconnected and interdependent faces of MSF, our Association and Executive, both play important roles in stimulating and guiding ethical discussions and identifying practicable solutions.

Humanitarian ethics is to be neither ideological nor judgemental. A process of humanitarian ethical reflection must provide a space within which different complex ethical positions can be articulated, developed, and challenged. This ethical space allows us to discuss key issues, take decisions or adopt a particular position, and to follow up with clear reasoning and justification. Whether or not consensus is ultimately achieved, it is imperative that all of those involved in decision-making processes should understand how and why a decision was taken. Much of our work is guided by a form of ethical intuition: an ‘ethical GPS’ developed within the organization over the course of the last forty-six years. Nothing can replace that intuitive capacity.

However, this does not detract from the need to engage with a process of more rigorous ethical reflection in relation to humanitarian action. Ethical reflection requires us to identify dilemmas before seeking solutions, to consider the various different interpretations of ethical issues, and to be open to different worldviews before making affirmative decisions. As more and more people are displaced by war and social upheaval, as access to safe and dignified places to seek sanctuary are denied, and as urgent needs go unmet, the ethical issues faced by MSF and other humanitarian organizations are surely set to intensify. We hope that by sharing our experiences and outlining efforts taken by MSF to actively develop its humanitarian ethical reasoning capacity, the organization can contribute to a greater awareness of the inherent dilemmas and challenges associated with the provision of medical humanitarian assistance, with the ultimate aim of improving humanitarian action for the benefit of the people we seek to assist.

Excerpted from “Humanitarian ethics in Médecins Sans Frontières/Doctors Without Borders: Discussing dilemmas and mitigating moral distress” by Rachel Kiddell-Monroe, Carol Devine, John Pringle, Sidney Wong and Philippe Calain, which appears in the book Humanitarian Action and Ethics, edited by Ayesha Ahmad and James Smith, first published in 2018 by Zed Books Ltd, The Foundry, 17 Oval Way, London SE11 5RR, UK. © Zed Books 2018.

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