Paper was presented at:
Regional Conference on Professionalism in Medicine 2006
Postgraduate Medical Institute, Singapore General Hospital

August 2006

Dr TAN Chi Chiu

Abstract

Medical aid is an immediate requirement in most disasters affecting communities, especially in developing countries. When local resources are overwhelmed, immediate projection of medical assistance from overseas can ameliorate the situation. Medical relief efforts sent overseas to disaster zones can vary widely in performance. However, medical humanitarian workers should endeavour to abide by the code of conduct of humanitarian work as well as their own professional code. The humanitarian ethic at work during crises has several operating principles, which are (a) Humanity, (b) Neutrality, (c) Impartiality, (d) Independence, (e) Respect, (f) Inclusion, (g) Empowerment and (h) Accountability. The medical professional code of conduct would be consistent with these principles. The professional code in a humanitarian context is no less onerous and obligatory than in normal practice, despite circumstances that mandate adaptation and modification of practices. Only when medical professionals exhibit professionalism in the field will they earn credibility as humanitarian workers of distinction.

Keywords:

Code of Conduct, Humanitarian Service, Medical Ethical Code

Introduction

The practice of medicine is only one highly specialised aspect of humanitarian assistance. Yet because it is an integral part of the broader contribution of humanitarian agencies towards alleviating suffering caused by natural or man-made disasters, medical professionals are obliged to abide by the wider principles of good practice and codes of conduct that define the ‘ethos’ of humanitarian work. Such principles are enshrined in documents such as the ‘Code of Conduct’ of the International Red Cross and Red Crescent Movement and NGOs in Disaster Relief. On top of that, medical professionals have their own ethical code to guide how they perform their work in the field. Medical professionals may contribute on a systemic basis, helping to build capacity within the indigenous health care system of a community at risk, or offer only short, sharp, acute relief to help a community when it is overwhelmed by a sudden catastrophic event. Even on a short term and limited scale, the organisation and the practitioners that provide service must keep an eye on the larger picture, to ensure that they are engaging the local community in the most appropriate way and delivering services that are not only beneficial but also defensible. This paper discusses the general ethical principles of humanitarian practice and shows how medical professionals can seek to abide by them. It also discusses the outworking of medical ethics in a humanitarian context.

The Humanitarian Ethic

The humanitarian ethic is to save lives and provide aid with dignity and according to needs. This ethic at work during crises has several operating principles, which are (a) Humanity, (b) Neutrality, (c) Impartiality, (d) Independence, (e) Respect, (f) Inclusion, (g) Empowerment and (h) Accountability. All other principles, including those of medical ethics, should be consistent with these.

Humanity, Neutrality Impartiality and Independence

In its purest form, neutrality and independence mean offering and providing aid without partisanship of any kind. Humanitarian workers should not take sides, not align themselves with any involved party, whether it is a war or a disaster situation. Aid must be provided solely on the basis of who has the need. In complex situations, this principle allows participants to gain access to the most needy without compromise. For example, aid agencies have the responsibility to provide appropriate aid that truly reflects the needs of the recipient community and not the priorities of the donor agencies or its backers.

It might seem at first sight that this is an easy principle for medical professionals to abide by. However, many medical teams are supported or sent by organisations that may have specific interests. For example, governments may choose to send teams from public health services or the military to countries which it has close diplomatic relationships, but make no such gesture to countries that may be even more needy, but which are less ‘important’.  On the ground, such teams may be constrained to work with partners that have specific relationships with the sending government, such as hospitals of the local ministry of health (even if they are already well supported) when other hospitals, which may be private or charitable, who have also taken in numerous patients are left unsupported. Or else it may be discovered that the local non-governmental organisation (NGO) that a national team is working with is related to the political party in opposition to the ruling government and the team is asked to realign it’s affiliations for political purposes, regardless of whether the best work is being done with that group. Religious groups may similarly work only with their counterparts, regardless of whether that is where they can make their best contribution.

Independence includes the responsibility to provide the best and most appropriate aid possible to bring, without interference by external parties as to the quality or quantity of aid given. Often, well-meaning agencies are manipulated by local players so that services and materials are diverted to specific groups, while others are ignored. Often there are political, religious or ethnic reasons for such discrimination. Aid agencies have to be alert to this hazard and must take steps to ensure that they have reliable, independent information as to where the real needs are. Medical services can similarly be subjected to such manipulations. 

In the professional realm, independence means the ability to give patients the best possible treatment without any degradation of quality caused by having to work with other players with lower standards. Ideally, medical teams should adopt a sector of responsibility, whether by community, ward or type of service, so that they can operate coherently amongst themselves. Working in piecemeal fashion in large teams comprising participants from numerous sources is a recipe for confusion, poor internal communications, inconsistent standards and possible adverse outcomes for patients.

Independence also includes an element of advocacy. In general terms, advocacy means exposing and condemning abuses, incompetence, corruption or criminal activity discovered in the process of providing aid. This is a controversial issue and many humanitarian agencies shy away from this aspect because there could be a backlash, humanitarian workers may be expelled or even killed. Of course advocacy need not be loud, public criticism during the mission, but can be a process of quiet, private dialogues after the mission is over. The real risk is that the agency loses its credibility as being impartial.

In medical service, advocacy may include speaking out when patients are being disadvantaged by action or inaction, for example, insufficient evacuation means being provided or discrimination in the way medical supplies are distributed. It may also take the form of a quiet word to hospital administrators about the unsatisfactory standards of another group of health workers. Hopefully, they will be redeployed where they can do less harm, but often, in a disaster, administrators are so stressed that they are grateful for any help they can get, even if in normal circumstances they would not countenance such poor standards. In one example, during the Singapore Team’s mission to the Pakistan earthquake in 2005, we were asked to join in the surgical care of a group of patients in a hospital. There were already in attendance a number of international surgeons. We soon discovered that many of the surgeries performed were either inappropriate or simply botched and it seemed that these surgeons were using victims for surgical practice. Appalled by this, we held discussions with the hospital administrators who admitted that they aware. They wanted the Singapore team to take over all the surgeries, but the other surgeons were already entrenched and the administrators did not know how to tell them to leave. That being the case, we saw no further surgical role for us in that hospital and we withdrew, leaving a small contribution of nursing care for post-operative wounds.

In another case, in Sri Lanka after the tsunami, we had the opportunity of running clinics in large displaced persons camps where there were many children who were either orphaned or separated from their parents. It was the local ministry of health that requested that we keep a look out for possible cases of child abuse or evidence of attempted trafficking by syndicates and to report these cases to the authorities. This was an advocacy role we happily accepted.

Respect

Apart from the value of collaboration, it is an attitude of respect that such local authority that is functional is not ignored. It is the height of arrogance to charge into town as a foreign hero come to save the natives from their own incompetence.  Local communities may be devastated, but they have their pride. They may appeal for international help, but they do not wish to be looked down upon.

One practical aspect of respect is the way aid agencies gain access.  When a government appeals in the international media for assistance, other governments respond directly. However even NGOs should have the courtesy to ask through the country’s ambassador if they are welcome. Sometimes, obtaining an official invitation takes time because governments have too many things on their hands and many groups feel justified in arriving uninvited and starting to do work however they can.

Medical professionals generally require licensing to practise in other countries. This requirement is often ignored when going into a disaster zone. But out of respect for host country relief doctors and nurses should offer to be registered prior to arrival. This can be done through the embassy. Often the grateful response is that the local ministry of health has given carte blanche registration to all overseas medical personnel coming in specifically for a relief mission. 

Respect also includes respect for local customs and norms. A disaster situation does not give permission for aid workers to behave as they please in the course of their relief work. At the most extreme end of misbehaviour, in 2002 a UNHCR report highlighted how aid agency workers in West Africa sexually exploited refugee children, thus destroying their credibility completely. Of course sexual abuse is simply criminal and violates universal customs and norms, not just local ones, but it is likely that the same abusers would not have taken similar liberties at home towards their own citizens.

In conservative Islamic societies, workers should dress conservatively and women may even cover their heads like the local women do. This was done in Pakistan despite difficulties caused by inexpertly placed scarves falling off or getting in the way of clinical work. It was also Ramadan at the time and the team took pains not to eat or drink in public view during the locals’ fasting time.

In the practise of medicine, respect has several professional implications. At the most basic level, although in a disaster scenario medical management must of needs be adapted and adjusted to the local situation, a victim should be offered a doctor’s best efforts with as little compromise as possible. In some cases, expired medicines have been brought into the field and used on patients when one would not do so at home. Where it is within the health provider’s control, and not in extremis, sub-standard procedures and medicines are inappropriate. In some locations in Thailand, where local authorities have detected the use of expired medicines, teams from Singapore are no longer welcome, and rightly so.

In an earlier example, the ultimate in disrespect and unethical as well, was the way poorly trained surgeons from overseas descended upon Pakistan earthquake casualties to use them for surgical practice. This flagrant disregard for the casualties’ right to proper treatment was abhorrent.

When doing medical relief work in community clinics, it is common experience that a large number of patients come with few or vague symptoms but asking for ‘medicine’. There are several explanations for this phenomenon. One is that the presence of foreign doctors gives them an unprecedented opportunity to see a doctor at all, whereas normally they may have very limited access to health care. They come to obtain medicines believing in ignorance that this can be kept for a rainy day. The other explanation is that may people in a devastated community suffer from mild to severe forms of post-traumatic stress disorder or grief reaction. This manifests in vague symptoms such as pains everywhere, headaches, insomnia, tiredness etc. These patients are genuine cases who are making a plea for help. Some relief workers have been observed to be very dismissive of such patients, regarding them as freeloaders or malingerers, or that ‘these people are just like that’. This contemptuous attitude is utterly disrespectful and inappropriate. If at home every patient deserves an ear no matter what their complaint, so it must also be in the field. Often a kind word, some reassurance or just a listening ear can go a long way in assuaging their trauma.

Inclusion and Empowerment

Inclusion and empowerment are interlinked. There is a fundamental philosophical divide when engaged in acute relief operations, whether merely to bring relief as quickly and efficiently as possible to the victims, or to engage local government or non-governmental players, trying to boost their capability to deal with the emergency at the present time (inclusion) as well as support their capacity building for the rehabilitation phase and beyond (empowerment). 

Where local infrastructure is destroyed (or non-existent) and where local community organisation is disrupted or fundamentally disorganised, it may well be more efficient and more cost effective to bypass what authorities are present to get to those in need quickly. But this should the exception rather than the rule, as total disorder is the exception (e.g. Aceh and Meulaboh) rather than the norm (e.g. Sri Lanka, Yogyakarta).

When a disaster strikes, local communities are the first to rise up and do their best to rescue people and give immediate aid. In some countries, local groups and NGOs are more effective than their own governments in providing acute relief and often are the first to tell the world of their plight. With some exceptions, usually in the most underdeveloped and remote regions of the world, local authorities and NGOs are organised, albeit overwhelmed. But they may well have a plan and are well aware of the needs that need to be fulfilled. External agencies, especially from overseas, actually have much less information. It is certainly not inappropriate for local authorities or agencies to remain in control of operations. Bypassing local authorities may undermine them, disrupt well-laid plans and may even be regarded negatively as political interference. 

Therefore active partnerships should be forged wherever possible.

In Yogyakarta during the Central Java earthquake of 2006, some local hospitals required all doctors and nurses to register at the operations room before being given access to the hospital. This was entirely appropriate as the hospital has the right to know who is entering the hospital to work on their patients, and to know that they are acceptable. In the Philippines Baguio earthquake of 2000, a major world power provided medical aid by sending medical teams into Baguio City and the countryside to distribute medicines at random, completely ignoring the local emergency health authority and its well laid plans. The Singapore team on the other hand, placed itself at the disposal of the emergency authority and in coordination with them was able to address needs much more accurately and efficiently. Similarly, in Sri Lanka, we placed ourselves under coordinating authority of the ministry of health at Galle, taking instructions from them each day as to where to deploy, but also acting as their reconnaissance elements in the field, providing up to date information on patient numbers, localities and needs. This harmonious relationship led to the Galle mayor declaring that the Singapore team did some of the best work in the area, even though there were other larger and better-equipped teams present.

The idea of empowerment comes with the corollary that external emergency assistance should not dis-empower the local populace. International agencies can undermine national and local capacities through overwhelming presence and dominance of the relief work. Local agencies then become supine and dependent, sometimes for the long term. One example is Nepal, where Singapore International Foundation used to run many projects. But the evaluation was that Nepalese society was not progressing well despite the presence of several hundred mainly international NGOs at work. Or maybe it was because of this enormous presence of international aid agencies that a culture of perpetual dependence had evolved. A balance needs to be struck. 

In Pakistan, Team Singapore helped the Pakistan Islamic Medical Association (PIMA) to set up, organise and run their emergency field hospital. Singaporeans very quickly became highly valued contributors. At the time we decided to finally disengage, we had numerous requests for further teams to come and continue working in the hospital on an indefinite basis. But we were resolute that our work was done. The period of greatest need was over. There was an endless need for basic medical services in the Muzaffrabad area that predated the earthquake, which we could not possibly see ourselves meeting indefinitely.  As it was, there was criticism that despite Pakistan being a large country with many hospitals in major cities, disproportionately few of their own doctors volunteered to come to the earthquake zone. Foreigners could not be expected to substitute for national self-help beyond the acute phase. 

Another argument is that international agencies have a responsibility to address not just the disaster per se, but also the root causes of vulnerability, including issues of poverty, marginalisation, government and environment. There is perpetual tension between short-term aims of immediate succour and long-term aims of providing development support. In practice, it is the larger agencies that are able to span the range. Organisations such as the Red Cross or those related to the United Nations have different branches dedicated to different levels of humanitarian assistance and may seamless transition from one sort of aid to another. 

Ideally, medical aid should extend beyond to treatment of injuries and acute illnesses to identification of health problems and constraints, selection of priorities, development of objectives and strategies, mobilisation of resources, implementation of activities and evaluation of short and long-term results. Smaller players such as independent medical relief teams obviously have a much more limited role. However, whereas they may not be expected to undertake longer-term projects for development, they have the ability and perhaps the responsibility to report on their activities and their findings to local authorities that may be able to use the information to plan subsequent work. Alternatively, small teams can pass information on to development agencies in their home countries that are likely to be involved in rebuilding, rehabilitation and future development work. An example is the rebuilding work supported by the Singapore Red Cross Society after the acute teams had done their part in Aceh. Another is Parkway’s offer of hospital and clinical services development training and advice to institutions in Galle following our relief mission there.

Accountability

Perhaps this is the most important principle. All humanitarian players have seven possible levels of accountability. 

1. The first is to the ideal of an ‘ethos’ of humanitarian assistance. This is supposed to be a universal code of ethics, which promotes principles of good practice and conduct. These principles are essentially those that have already been discussed. 

2. The second level is accountability to the community or country of origin where this is the primary authority of the agency. This involves societal values based on the social and political system of the community. 

3. The third level is the organisation’s internal value system, which is based on its constitution, its board of directors, the management and practitioners. This is particularly important for international agencies not aligned to any single country, but which have broad based influences through international boards. It also involves external funders such as corporations and governments who are able to influence priorities and behaviour. 

4. The fourth level is the professional level, wherein lies the ethical code and guidelines within which specific professional work is performed, be it engineering, accounting or medicine.

5. The fifth level is the personal ethical system of practitioners, shaped by culture, religion and individual beliefs. 

6. The sixth level is the range of responsibilities under civil and criminal law, such as duty of care, fiduciary duty or trust and protection responsibilities amongst others.

7. Finally, humanitarian workers are ultimately accountable to their ‘clients’, that is the recipients of their aid. Increasingly, recipient countries are being more selective in accepting humanitarian aid and agencies that have a good reputation are more likely to be invited in, and those who fail to maintain standards can be shown the door.

In trying to be accountable at all levels, organisations find themselves under pressure from many competing influences. For example, an organisation that is funded by government or by the private sector may find itself needing to satisfy political or commercial interests over purely humanitarian ideals. Internally, there may be tension amongst Board members about what direction to take. Add to this, cultural issues, local customs, individual proclivities amongst management and professionals, and pressure from peer organisations competing in the same environment, and it is easy to see how an organisation may become distracted from its primary mission. It is important to have continuous dialogue amongst all involved parties for a generally acceptable organisational ethos to be arrived at, and which will be experienced by recipient communities.

Professional accountability in medical aid reflects the ethics and code of conduct of the body of professionals the workers represent. For Singaporean doctors, they are expected to abide by the Ethical Code and Guidelines promulgated by the Singapore Medical Council, as well as the ethical guidelines of the Singapore Medical Association, modified only by exigencies of circumstances. Many of the ethical principles espoused when applied to overseas humanitarian assistance, can be seen to flow logically from the humanitarian code of conduct, as discussed above. It should be no surprise that doctors are expected to deal with disaster victims with the same standards that are applicable to their daily practice. Medical ethics are particularly important in humanitarian work because this aid is highly personal and immediately life-changing. No different from a non-disaster context, trust in doctors is paramount and doctors carry a high level of responsibility. 

Medical Ethics

If we look at the SMC’s Ethical Code and Guidelines (2002) we can see how it can applied to humanitarian aid:

• To be dedicated to providing competent, compassionate and appropriate medical care to patients.

• It is important even in a disaster situation not to practice beyond competence, thus putting patients at risk of adverse outcomes. No patient should be a doctor’s ‘training ground’ unless properly supervised in circumstances where the benefit to patients outweighs the risks. Wherever possible appropriate referrals should be made. 
• Appropriate medical aid includes making careful decisions about conservative versus surgical treatment. For example, implant surgery for fractures under less than ideal conditions may be completely inappropriate and even dangerous. 
• It goes without saying that compassion is essential.

• Be an advocate for patients’ care and well-being and endeavour to ensure that patients come to no harm.

• Especially where the situation is confused and dangerous, doctors in the field must act always in patients’ best interests and be their advocate.
• Where doctors in the course of their work find evidence of violation of human rights or evidence of torture or mutilation as a means of punishment, they have a responsibility to report this to the relevant authorities. If it is inappropriate or unsafe to do so during the project, expose can be done afterwards.  
• Doctors’ responsibilities even extend to reporting or interfering with other medical teams’ actions if we sincerely feel that they are harmful to patients.

• Provide access to and treat patients without prejudice of race, religion, creed, social standing, disability or financial status. A doctor shall also be prepared to treat patients on an emergency or humanitarian basis when circumstance permit.

• In going into a disaster zone, a doctor essentially fulfils his humanitarian obligations. However, because of limited resources, triage may be required to prioritise treatment for the most needy. Doctors must exercise sound judgement and defensible actions.

• Abide by all laws and regulations governing medical practice and abide by the code of ethics of the profession.

• Where there are local laws and regulations governing practice, they should be obeyed when possible. This includes registration of doctors.  

• Maintain the highest standards of moral integrity and intellectual honesty.

• Medical treatment should be according to evidence based medicine or good clinical practice, allowing for variations mandated by circumstances.
• Expired medicines or materials should not be used on humanitarian casualties unless unavoidable.

• Treat patients with honesty, dignity, respect and consideration, upholding their right to be adequately informed and their right to self-determination.

• Disaster casualties may be helpless, but they deserve respect. Simple things like providing privacy during clinical examinations or a chaperone for a female patient are important where it is possible to do so. Language problems notwithstanding, each patient should be adequately informed about their condition and the treatment offered. Although it is rare for patients to exercise ‘self-determination’ during a crisis, doctors need to be sensitive to this where a patient is able to exercise choice. 
• Within this principle should be included respect for local customs and culture.

• Maintain a professional relationship with patients and their relatives and not abuse this relationship through inappropriate personal relationships or personal gain.

• Humanitarian aid must not come with expectations of reward or favours from patients. Certainly there should never be any kind of personal relationship with patients that in normal practice at home might be deemed inappropriate. 

• Keep confidential all medical information about patients.

• Within reason, this principle should be sustained. Where it is in patients’ interest for their medical records to be shared so that continued management is possible, this should be done. This is especially important when handing over a service to local agencies after a medical team’s engagement is over. 
• A corollary to this principle is that doctors should maintain a high standard of professional communications, so that patients are properly handed over from one shift to another or from one team to another. There are numerous examples of such poor clinical record keeping that after the departure of a medical team, no one has any idea what surgeries had been conducted on patients left behind.

• Regard all fellow professionals as colleagues, treat them with dignity, accord them respect and manage those under supervision with professionalism, care and nurturing.

• This is applicable to our attitude towards other nations’ medical personnel and services. Even if the host community is less developed than our own, we should not display disdain, contempt or criticise our professional colleagues gratuitously.  When working with local staff, they should be managed, taught and supervised with due respect.
• This also includes the way medical teams in the field are managed by the team leaders. Members may be under severe stress due to working and living conditions, or they may feel overwhelmed, helpless and hopeless in the face of suffering. They need support, counselling and opportunities to ventilate their feelings. They should be taught how to handle themselves in the field and how to perform their professional duties better in the circumstances.

• Be open, truthful, factual and professionally modest in communications with other members of the profession, with patients and with the public at large.

• Our attitude towards our patients in the field and our colleagues in the host communities should be modest, yet truthful. If there are areas ripe for improvement, we should say so and give our advice, but always with an attitude of humility and a genuine desire to help to improve things.

• Maintain professionalism in informing the public about services, ensuring that information projected is purely factual and devoid of any attempt at self-aggrandizement.

• Although this principle deals with advertising, it applies to medical aid workers when speaking about our humanitarian work to the public, whether in the host country or back home. It is tempting to portray ourselves as saviours and heroes, surviving dramatic expeditions. Melodrama should be resisted. Doctors should not normally boast to the public about their triumphs let alone their routine achievements and this is no different.

• Keep abreast of medical knowledge relevant to practice and ensure that clinical and technical skills are maintained.

• It is an aspect of professionalism how doctors adapt their skills to various circumstances in the field. There is a large body of experience, much of it in literature, on how to adapt medical and surgical treatment to less than ideal conditions. Keeping abreast of this kind of knowledge and skills will equip doctors to perform better in a humanitarian setting.

• Participate in activities contributing to the good of the community, including public health education.

• Wherever possible, medical teams should not only treat illness and injury, but also add value to their work by providing public health education to promote health and prevent disease. This is often done in collaboration with local workers and interpreters.

• Endeavour to abide by the Ethical Code when making use of modern or new technology in treatment modalities, communication means or information handling.

• Doctors must try to abide by good practice principles when having to put up with very basic and perhaps backward technology and equipment. Doctors must do their utmost to provide the best treatment they can in the circumstances.
• On the other hand, doctors must resist the temptation to employ state of the art techniques or equipment, when it is inappropriate for the circumstances.

Conclusion

Ethics, both institutional and individual are crucial for delivering effective humanitarian aid that respects individuals and communities. Every organisation and participant involved in humanitarian aid must develop and internalise a set of principles and standards that form their own code of conduct. Professionals in addition must abide by their own specialist code of ethics, which must be consistent with the broader ethical principles guiding all of humanitarian assistance. Doctors are no exception and while we have the ability to provide essential aid to casualties of a disaster, we must be very careful to do so without undue compromise to our own ethical code and guidelines. Evaluation of relief projects should be done through tools based on the Code of Conduct for humanitarian operations, as well as applicable professional ethical codes.