Date Published: March 20, 2017
Publisher: Public Library of Science
Author(s): M. Murat Civaner, Kevser Vatansever, Kayihan Pala, Animesh Biswas.
Natural disasters, armed conflict, migration, and epidemics today occur more frequently, causing more death, displacement of people and economic loss. Their burden on health systems and healthcare workers (HCWs) is getting heavier accordingly. The ethical problems that arise in disaster settings may be different than the ones in daily practice, and can cause preventable harm or the violation of basic human rights. Understanding the types and the determinants of ethical challenges is crucial in order to find the most benevolent action while respecting the dignity of those affected people. Considering the limited scope of studies on ethical challenges within disaster settings, we set upon conducting a qualitative study among local HCWs.
Our study was conducted in six cities of Turkey, a country where disasters are frequent, including armed conflict, terrorist attacks and a massive influx of refugees. In-depth interviews were carried out with a total of 31 HCWs working with various backgrounds and experience. Data analysis was done concurrently with ongoing interviews.
Several fundamental elements currently hinder ethics in relief work. Attitudes of public authorities, politicians and relief organizations, the mismanagement of impromptu humanitarian action and relief and the media’s mindset create ethical problems on the macro-level such as discrimination, unjust resource allocation and violation of personal rights, and can also directly cause or facilitate the emergence of problems on the micro-level. An important component which prevents humanitarian action towards victims is insufficient competence. The duty to care during epidemics and armed conflicts becomes controversial. Many participants defend a paternalistic approach related to autonomy. Confidentiality and privacy are either neglected or cannot be secured.
Intervention in factors on the macro-level could have a significant effect in problem prevention. Improving guidelines and professional codes as well as educating HCWs are also areas for improvement. Also, ethical questions exposed within this study should be deliberated and actualized with universal consensus in order to guide HCWs and increase humane attitudes.
The classical definition of the term “disaster”, which provides a clear distinction from “emergency” is “A situation or event which overwhelms local capacity, necessitating a request on the national or international level for external assistance” . This imbalance hampers healthcare systems due to the increased needs of population, direct damage on infrastructure and loss of healthcare workers (HCWs). HCWs work in conditions different than their daily routine, as there are a number of stressors such as heavy workloads, limited resources, security concerns regarding themselves, relatives, and patients, absence of firm guidance in international law and health policy and the diversity of cultural backgrounds and language barriers [2–4]. A dramatic environment which demands urgent and vital action might pose different kinds of value problems while making life and death decisions by triaging patients, coping with the problems related to relief, or carrying out research within the affected population.
During and after the analysis, it was found out that the results of the study could be classified and presented under different categorizations according to disaster types (some have unique problems comparing to others), to the different parties of the problems, or to the periods of disasters (before-during-after). In order to see the connections between the problems and their determinants, we have considered the ethical problems on different levels or layers. Therefore we have classified the ethical problems that HCWs face, not just specific to healthcare provision, but also to the issues on a larger scale.
In this study, the aim is to understand the types, nature and determinants of ethical problems emerging in disaster settings; therefore we have limited interpretation of the results within this viewpoint. However, we realize that there are many questions to be answered relating to ethical problems and the arguments of participants, so we have stated them as the first steps for an ethical analysis of the dilemmas.