It is only a matter of time before covid-19 gains a foothold among refugees, internally displaced persons, and other vulnerable populations living in humanitarian settings. As humanitarian organisations mobilise to build covid-19 treatment centres, and scale up community-based approaches to case management, we need to consider the resilience of the humanitarian workforce. Our internal evaluations of the Save the Children Ebola response in West Africa highlighted the need for better support for frontline staff who invariably find themselves grappling with the demanding ethical dilemmas inherent to large-scale outbreak responses in humanitarian settings. Given the high likelihood of moral distress, the question is how to prepare our staff for what is to come.

Moral challenge

This outbreak will likely prove especially troubling given the breadth and severity of the needs in contexts defined by power imbalances, complex political contexts, extreme shortages of basic health goods, and a lack of external controls over the work of humanitarian actors. Areas of ethical tension will almost certainly include the allocation of scarce resources, discontinuing care or closing to new admissions (both for covid-19 cases and those with other morbidities), “complicity” in coercive measures, care for staff amidst (PPE) supply shortages, and prioritisation vis-à-vis pre-existing crisis needs. Complicating factors may include the differences between the ethical orientations of different professional groups, such as between clinical ethics and humanitarian health or public health ethics, or an unfamiliarity with the weight or value that principles hold within a given context and culture.    

How should humanitarian organisations respond?

Ethically informed best practice sets out clear goals, but does little to alleviate moral distress when these goals are unattainable or in conflict. Humanitarian responses to covid-19 will confront fieldworkers with situations where all principled options lead to harm; this is unavoidable. The way forward lies in establishing a culture that avoids divisive arguments over right and wrong, and instead considers how the various options bring both benefits and harms. This realisation places a premium upon procedural ethics: the process by which decisions are made. 

Organisational support is therefore an obligatory aspect of an organisation’s duty of care. In addition to supporting ethically coherent decision-making processes, organisations must also:

• Signal the importance of ethics; for example, by devoting resources to addressing the main ethical issues facing humanitarian health, by articulating humanitarian principles and through the provision of support to individuals in distress. 
• Provide staff with information about expected conditions and the most relevant ethical issues at the pre-departure stage and on an ongoing basis.
• Recruit and deploy the right people, based on their experience, technical expertise, and suitability for working with such potentially ethically compromising circumstances. Some people struggle with moral ambiguity more than others.
• Pre-empt frontline staff having to take unsupported individual or ad hoc decisions by providing clear and flexible guidelines for action, particularly in relation to extremely serious decisions such as withdrawing or withholding life-saving treatment.  
• Ensure team support such as regular team debriefings that include guided discussion about real world ethical dilemmas, and deliberate mentoring.  
• Provide ongoing training and resources for managing challenging ethical issues, including scenario-based training that reinforces skills in how to identify ethical issues and respond to them as a team.  In certain circumstances, professional ethics support may be warranted. 
• Employ frameworks or tools to help decision making in the face of ethical problems. A framework cannot function as a formula: it assists decision-makers in weighing/balancing competing principles and interests.

A final word

In the end, much will be left behind as humanitarian organisations scramble to deliver urgent assistance in the covid-19 crisis. Long lists of best practice ethical guidelines may prove paralytic to overworked field teams, or inadvertently increase the pressure to make the right choices. The question at hand for humanitarian leadership: What are the moral values that we seek to fulfil in an outbreak response and how do we translate these values into our strategic, programmatic, and individual choices?

Marc DuBois, Department of Development Studies, SOAS University of London

Julian Sheather, Médecins Sans Frontières/Doctors Without Borders (MSF)

Catherine R. McGowan, Department of Public Health, Environments & Society, London School of Hygiene & Tropical Medicine; and Humanitarian Public Health Technical Unit, Save the Children UK

Louisa Baxter, Humanitarian Public Health Technical Unit, Save the Children UK

Rachael Cummings, Humanitarian Public Health Technical Unit, Save the Children UK

Competing interests: None declared