Ethical Issues in Humanitarian Work: Perceptions of Humanitarian Ethics Experts, Workers, and Non-Governmental Organization Members

Valgimigli, Federico; Côté, Louis; Drolet, Marie-Josée

doi:https://doi.org/10.7202/1124206ar

introduction

Humanitarian work involves providing aid and protection to people adversely affected by crises such as complex emergencies arising from unstable political contexts, armed conflicts, and severe shortages of essential resources like food, medicine, and shelter. This work has evolved from immediate relief efforts to include long-term, meticulously monitored assistance (1-4). Humanitarian work is carried out by a diverse array of actors including national or international non-governmental organizations (NGOs), local populations, and governmental bodies, all working together to manage and alleviate crises. This has led to an ever-growing body of research and literature regarding its complexities and issues. Our previous study on the conceptualization of ethical issues in humanitarian work (5) highlighted the importance for humanitarian workers to identify and understand the ethical issues they may encounter. This understanding is crucial for assessing the associated risks and developing prevention and management strategies. In the current study, we define an ethical issue as any situation that potentially compromises the respect of one or more moral values or principles deemed important (6). Humanitarian workers face numerous ethical issues that are both complex and enduring (7). Research indicates that humanitarian work necessarily involves risks, especially given the high-pressure, resource-scarce environments in which workers often operate (8-13).

Our previous comprehensive review of the international literature on ethical issues in humanitarian work, conducted between 2018 and 2021, revealed a field dominated by descriptive or theoretical ethics (14). While valuable, there was a notable lack in comprehensive, empirically documented perspectives on the ethical landscape in humanitarian work; empirical research was sparse, with only 19 of the 84 articles we reviewed providing empirical data.

Table 1

**Summary of empirical research on ethical issues in humanitarian work**

Table 1, which summarizes the key characteristics of these 19 empirical studies and formed the foundation of our previous conceptual work (5), here serves two purposes. First, it illustrates the limited scope of existing empirical research. Second, it highlights a crucial gap that motivated our present study: the perspectives of diverse humanitarian actors have not been sufficiently triangulated, with most studies focusing narrowly on healthcare professionals. This prior analysis convinced us of the need for more empirical research that engages with varied group of participants — including not only field workers but also NGO members and ethics experts — to develop a better understanding of the ethical issues at play.

The nineteen empirical studies reviewed comprise ethical issues pertaining to resource allocation, context, organizational and individual competency, impact and effectiveness of aid, corruption, professionalism, patient-healthcare worker relationships, emotional stress, palliative care, psychological impact, cultural and operational adjustments, high-risk settings, power imbalances, and sustainability.

Resource allocation and fair use are significant ethical issues that require tough decisions about prioritizing aid and managing often scarce resources (16-21). Ethical issues related to context involve public authorities’ defensive attitudes and resistance to cooperation, the media’s irresponsible coverage, and relief organizations’ sometimes imperious approaches. These factors complicate effective humanitarian work and raise concerns about transparency and respect for the affected populations (4). Organizational and individual competencies also present ethical issues, including inadequate coordination and insufficient supplies, which can lead to compromised aid quality and inefficient resource use (4,16,22). Additionally, concerns about the impact and effectiveness of humanitarian work focus on the perpetuation of dependency and inequity (16). Humanitarian work may inadvertently support undesirable governmental actions or misuse resources, complicating the identification of ethical duties (22).

Furthermore, corruption and ethical compromises, both local and systemic, can undermine the integrity of humanitarian work (16). Issues of professionalism and interpersonal responses include improper behaviour of humanitarian workers, which can compromise aid integrity (16,17,21). Patient-healthcare worker relationships encompass a range of ethical issues, such as the adequacy of healthcare workers’ professional competence, the application of triage, limits of duty to care in dangerous conditions, respect for patient autonomy, and the preservation of confidentiality and privacy (4).

Humanitarian workers often face significant emotional and ethical stress due to exposure to extreme crisis situations. This stress can lead to feelings of isolation, burnout, depression, and guilt due to the moral implications of resource allocation and the emotional weight of providing or failing to provide adequate care (10,12,16,21,24). Similarly, ethical issues in humanitarian palliative care involve balancing life-saving treatments and alleviating suffering, causing moral distress among healthcare providers who struggle to ensure dignity for dying patients while managing limited resources, systemic constraints, and cultural sensitivities (10,25).

Cultural and operational adjustments further complicate ethical issues, especially in high-risk settings. Here, humanitarian workers must navigate operational hurdles and cultural differences while managing their ethical implications (17,21,26). In such settings, direct attacks on healthcare facilities, border closures, and access restrictions force workers to balance safety and care obligations (18,21,22). Ethical issues pertaining to power imbalances and cultural sensitivity require respectful and effective interventions. Humanitarian workers must manage their influence over program priorities and interactions to respect local cultures and avoid perpetuating colonial dynamics, ensuring mutual respect, and understanding in high-risk environments (17,27). Lastly, ethical issues concerning the sustainability and long-term impact of humanitarian work involve ensuring aid quality and sustainability, determining appropriate standards, and managing transitions responsibly to sustain benefits post-closure (28,29).

Given the dearth of empirical research, particularly studies that triangulate the views of different humanitarian actors, further investigation is required to facilitate a more nuanced understanding of ethics in this field. The reviewed empirical literature, as summarized in Table 1, has primarily focused on the experiences of healthcare workers and, to a lesser extent, NGO members. We have not found the perspectives of humanitarian ethics experts empirically documented. To address such blind spots, our study adopts a multi-perspective approach, triangulating the insights of humanitarian workers, NGO members, and humanitarian ethics experts. We specifically sought to engage individuals with diverse knowledge and experience, from on-the-ground practice to administrative oversight and academic reflection. We thus aimed to build upon the existing literature by providing a richer, more comprehensive empirical account. With these considerations in mind, we conducted an empirical qualitative study to answer the broad question, “What are the ethical issues in humanitarian work?”, documenting the perceptions and experiences of a heterogeneous group of humanitarian participants.

METHODS

This section presents the methods used for the research in six parts. First, we present and justify the research design, then describe the sampling methods used to form the study sample, as well as the methods employed to recruit study participants. Subsequently, we specify the data collection and data analysis methods we employed. Finally, we outline ethical considerations.

Research design

Given the paucity of empirical research to date on the ethical issues raised by humanitarian work (14), and the scarcity of empirical studies in this field that have documented the cross-perceptions of different humanitarian actors, an inductive qualitative design was chosen (30,31). Since the phenomenological design is recommended for documenting the perceptions of various actors regarding the ethical issues arising from diverse practices (31), a descriptive phenomenological design inspired by Husserlian philosophy guided the present study (32,33).

Sampling

A purposive sampling approach was employed (34). To ensure a rich, varied, and comprehensive perception of the investigated phenomenon, a triangulation of sources was decided upon (35). This involved recruiting participants with diverse and complementary characteristics, particularly considering the social roles they occupy in the specific context of humanitarian work. Given that ethical issues may be perceived and experienced differently depending on an individual’s social role (36), and that few empirical studies to date have opted for triangulation of their sources, the sampling strategy aimed to capture this diversity. Thus, three types of participants were sought: 1) humanitarian workers; 2) members of a humanitarian NGO; and 3) experts in humanitarian ethics, i.e., academics, philosophers or ethicists who teach humanitarian ethics, research humanitarian work or are considered thinkers with a specialization in humanitarian ethics.

Following Thomas and Polio’s (37) recommendation to recruit between six and twelve participants to ensure data saturation when using this research design and taking into account that our sample would be heterogeneous, a number between nine and fifteen participants was targeted to ensure data saturation, i.e., between three and five participants per category. This meant recruiting three to five humanitarian workers, three to five NGO members and three to five humanitarian ethics experts. Finally, regardless of their role, to be included in the study, all participants had to be able to speak and understand English or French and had to be willing to take part in the study.

Participant recruitment

Several strategies were used to recruit participants. For humanitarian workers and NGO members, emails were sent to various NGOs to gauge their interest in participating in the study. To recruit humanitarian ethics experts, emails were sent to academics, philosophers, and ethicists known for their expertise in the field of humanitarian ethics, based on their reputation and published work on the subject. Additionally, individuals known to this research team members — whether humanitarian workers, NGO members, or ethics experts — were approached to participate in the study. Finally, participants were invited to identify others who might potentially be interested and share these contacts with the research team.

Data collection

Two tools were used for data collection: 1) a sociodemographic questionnaire; and 2) semi-structured qualitative individual interview guides designed specifically for this study. English and French versions of both documents were available, according to participants’ preferences. The socio-demographic questionnaire collected data to describe the sample. Interview guides contained the same set of questions but were adapted to the specific role of the participants. This customization ensured that each question was relevant to participants’ daily realities. When participants were contacted, they were asked in what capacity (role) they wished to take part in the research and agreed with the research assistant on a date and a time to take part in the interview.

Interview guides comprised two parts: an introduction and a section on ethical issues. The introduction consisted of general questions designed to put the participant at ease. For example, “Tell me what a typical working day is like for you”. The section on ethical issues was designed to capture participants’ perceptions of the phenomenon under study through questions such as these: “Tell me about any stories you’ve experienced in your humanitarian work that involve, in your opinion, an ethical problem or issue? In your opinion, what are the main ethical issues in humanitarian work? Please give examples.” Finally, although some interviews were conducted in person, most were conducted online or by phone. Interviews were digitally recorded so that verbatims could be transcribed in full. Interviews lasted between 40 and 120 minutes, depending on the participants, with an average duration of 90 minutes.

Data analysis

Data collected via socio-demographic questionnaires were subjected to simple descriptive statistical analysis (i.e., totals and averages). The semi-structured interviews were analyzed qualitatively, following the steps proposed by Giorgi (38) to achieve a Husserlian phenomenological reduction. After collecting and recording the participants’ narratives, research assistants transcribed the interviews in their entirety. Repeated reading of the verbatims enabled a team of analysts to draw up a synopsis, i.e., an initial extraction of the units of meaning, for each of the interviews. Each synopsis was then re-read and commented on by a second team of analysts. A third team of analysts analyzed the final version of all the synopses and verbatims. This team brought together all the analyses to generate and organize the final and unified units of meaning emerging from the qualitative narrative data. Given that several interviews were conducted in French, after full transcription of participants’ narratives these were translated to English for publication purposes.

The final, unified units of meaning were organized into broader themes. This was an inductive process, grounded in the data itself, where we carefully compared and contrasted the verbatims from all participant interviews to identify recurring patterns and core concepts. To ensure both methodological rigour and clarity, and inspired by sociological approaches that analyze phenomena at different levels (39), we structured the resulting themes to reflect three distinct levels of analysis: the micro-level (individual, pertaining to issues experienced directly by individuals, such as value-based tensions), the meso-level (organizational, pertaining to issues related to organizational structures and practices, such as resource scarcity and political considerations) and the macro-level (structural, pertaining to overarching ideological and systemic issues, such as neocolonialism). This multi-level framework allowed us to present the findings in a structured manner, moving from the more personal experiences of humanitarian actors to the broader systemic forces that shape the ethical landscape of their work.

Ethical considerations

Before beginning participant recruitment, the principal investigator obtained ethical certification from the Comité d’éthique de la recherche avec les êtres humains of the Université du Québec à Trois-Rivières (UQTR). All members of the research team signed a confidentiality agreement. All research participants signed the consent form after reading the research information sheet, thus ensuring their free and informed consent.

Results

This section presents the results of our study in two subsections: 1) a description of the study’s participants, and 2) the ethical issues discussed.

Participants

This study included fifteen (n=15) participants, of whom ten (n=10) identified as female and five (n=5) as male. Participants’ ages ranged from 28 to 63, with an average age of 35. The most frequent age for participants was 62 (20%), and over 50% (n=8) of participants were over 40 years of age. Moreover, 80% of participants were white (n=12) and most (n=12) were born in Western countries, predominantly Canada (n=7), while others were born in Asia (n=2) or Africa (n=1). Participants had occupied different humanitarian roles: humanitarian workers (n=8), ethics experts (n=4), NGO members (n=3). Of the humanitarian workers interviewed, five (n=5) were in nursing or other healthcare professions and three (n=3) were healthcare professional interns, and all NGO members worked in development aid. As for ethics experts, they had theoretical perspectives informed both by their hands-on experience in humanitarian field operations and by their relations with other people who do such work. Participants had been involved on average with at least 2 organizations, with 2 participants having worked with more than 6. The humanitarian work experiences ranged from 0.17 years (2 months) to 35 years; 40% of participants had less than 5 years of experience while 20% had more than 25 years of experience. In terms of education, 33% (n=5) of participants had doctorates, 27% (n=4) had bachelor’s degrees, and 13% (n=2) had pursued postdoctoral studies; other participants (n=4) had qualifications including master’s degrees, diplomas of specialized higher studies (DESS), certificates, and diplomas of college studies (DEC). Finally, twelve (n=12) participants have some knowledge of ethics, and three (n=3) do not. Nine (n=9) participants with ethics knowledge declared having taken one or many university courses entirely dedicated to ethics (n=6), having completed a few hours or days of ethics training (n=2) or holding a university degree dedicated to ethics (n=1).

Ethical Issues

This section groups our findings into four distinct themes of ethical issues arising in humanitarian work: 1) value-based tensions; 2) resource scarcity; 3) political considerations; and 4) neocolonialism (Table 2). These themes broadly encapsulate the ethical issues in humanitarian work on the micro-level (i.e., individual issues), the meso-level (i.e., organizational/institutional issues) and the macro-level (i.e., political and ideological issues). We discuss each in turn.

1. Value-based tensions

The theme of value-based tensions comprises ethical issues experienced by humanitarian workers in the field. They may arise in international missions, in NGO administrative offices, or in academic settings. Such issues involve making difficult decisions between conflicting values or requirements of the profession. In analyzing the data from the interviews, four concepts of ethical issues pertaining to value-based tension emerged: A) intercultural value conflicts; B) care versus protection of workers (NGO); C) care versus collaboration; D) emergency versus long-term care; and E) ethical silence (Table 3).

Table 3

**Ethical issues related to value-based tensions**

A) Intercultural value conflicts

Humanitarian workers often deploy in emergencies, which can range from war zones and disaster-stricken areas to regions affected by pandemics. When humanitarians work outside their home country, conflicts may arise between their values and those of local cultures. Such value conflicts may also arise between local NGO partners and international workers. Nine study participants highlighted the need to navigate intercultural value conflicts. For instance, one participant noted a significant ethical issue regarding local perceptions of sexual violence and the refusal of pregnancy termination for rape victims by local staff:

The final ethical dilemma is the different cultural perception of [...] people who are victims of sexual violence. In our team, we had a local staff who saw sexual violence in a certain light and refused, for example, to terminate the pregnancy of a woman who had been raped. There were obviously a lot of tensions concerning values and the status of women comparable to livestock in certain countries

P1

Another participant discussed the difficulty of respecting local culture while addressing practices perceived as unacceptable. This can lead to irreconcilable value conflicts, with colleagues insisting that such practices are part of the local culture, making discussions nearly impossible:

[...] how can we both assert respect for culture, and at the same time assert that there are practices that are not acceptable [...]. But there are a lot of misunderstandings here, and I’ve had practically impossible discussions with colleagues who said: “No, no, we won’t get into it, it’s part of the culture.” A conflict of values that’s hard to reconcile

P2

One participant also emphasized the need to set aside personal values for professional conduct:

You must put your own values aside [...]. I can have a very clear opinion on abortion, for example, but if I allow my perception to colour my speech, well, then I’m no longer being professional

P8

Conversely, another participant highlighted the operational needs of a hospital during Ramadan, critiquing the myopic view that could impede patient care, which should always be the top priority:

Like this is a hospital that has to run regardless [of Ramadan]. So, they had this very, like, I would say this myopic view of what is right or wrong. The patient care and the functioning of the hospital is priority number one

P12

Ultimately, then, intercultural value conflicts in humanitarian work require balancing respect for local cultures with addressing perceived practices and maintaining professional conduct.

B) Care versus collaboration in a context of corruption

Humanitarian NGOs often face ethical issues when operating in regions governed by local powers whose values and ways of proceeding may conflict with their own. To that point, four participants discussed the ethical issues arising from the need to collaborate with local authorities or, in some cases criminal organizations, to deliver essential care.

One participant noted the disproportionate allocation of government budgets, greater parts of it directed towards military expenditures than towards healthcare. Thus, NGOs were required to fill the gap:

Invariably, as a medical NGO, you end up providing the healthcare services that the government should be offering its population

P1

Another participant pointed to the prevalence of governmental corruption encountered by NGOs:

I’ve worked with NGOs that were very aware, among other things, that there was a lot of corruption at government level, that certain departments were supposed to hand over funds to us but weren’t doing so

P5

Finally, another participant addressed the extreme measures required to operate in certain areas controlled by armed gangs. They raised a critical question regarding the ethical implications of engaging with such groups:

To enter these neighbourhoods, you must collaborate with armed gang leaders. Do we accept to engage, to deal, and to collaborate with armed gangs?

P14

Overall, participants’ insights revealed that the provision of care often involves compromising with local powers that may not necessarily align with the NGOs’ values and ways of working.

C) Ethical silence

Ethical silence, which corresponds to the tendency of a person to keep their ethical concerns to themselves for various reasons, may arise from complex reasons such as fear of personal consequences, notably job loss, and awareness of the overall benefits that NGOs provide despite their flaws. Workers may withhold reporting illegal or questionable activities due to the potential repercussions on them or others. Seven participants discussed this issue.

For instance, one participant explained that:

As far as ethical silence is concerned: for some years now, certain employees have been aware of a certain organized system of theft of medical equipment but were unable to denounce the situation. Because it put them in danger

P1

Similarly, concerns about losing one’s job and facing negative judgments can suppress voices, especially in performance-driven organizational environments:

But of course, there was also the question of losing one’s job, of negative judgment. That’s a concern that’s becoming very important in organizations where management styles are very much based on performance. [...] And that translates into isolation, ethical silence, or silence altogether

P2

Further, another participant pointed out that people who witness questionable management styles or decisions often remain silent to maintain their positions, despite recognizing irregularities:

I have been locked in a lot of bureaucracies for the last 5 years, rather than in the headquarters, rather very operational. I can see that in headquarters, I can see people keeping their jobs as they’re not speaking out about often [authoritarian] management style or decision-making that seems strange to them or whatever

P4

Another participant (P5) explained that this silence was also prevalent when corruption was involved, with individuals refraining from speaking out due to fear of retaliation, such as repercussions on family members working in government or on personal benefits.

Moreover, one participant described how the hierarchical structure within NGOs can discourage whistleblowing:

Let’s say local staff confide in you that such-and-such a person is doing malpractice, either stealing or abusing, sexual intimidation, and then not being able to talk about it [...]. That’s right, because managers, at least at that time, weren’t open to it. And even taking it up with the general manager was like bypassing the managers. In the end, there was a situation that went on for years, that everyone knew about, and nothing was done about it for a long time

P14

Additionally, another participant explained that international workers sometimes had to silence themselves to avoid conflicts or repercussions from host governments:

Sometimes […] we have not been able to speak out vey openly about our concerns about the Bangladesh government’s sort of management of things, because of concern that they might not accept anymore visas or like withdraw NGOs or whatever

P12

These excerpts show how ethical silence can result from a combination of fear, external pressures, and sometimes problematic organizational cultures, which discourage workers from speaking out.

D) Emergency versus long-term care

Five participants also identified ethical issues arising from the need to prioritize between emergency and long-term care. Humanitarian NGOs typically operate with specific missions and may be active in the field for prolonged periods. However, when emergencies occur, immediate responses often become prioritized. This can result in the neglect of non-emergency issues, either because they fall outside NGOs’ defined missions or due to limited resources, leading to a significant divide between emergency response and long-term care.

For instance, one participant noted the frequent challenges faced by the NGO she was working for at the time:

[There is a] difficulty for [this NGO] missions in managing chronic illnesses. Diseases such as diabetes, hypertension, non-infectious diseases that are still in their early stages [and] certain cancers. Of course, these are fairly typical cases

P1

Participant 4 highlighted another common issue: whether to prioritize long-term health support for a few people with chronic diseases or to focus on more immediate primary health care programs. Additionally, both participants 14 and 15 pointed out that in emergency situations, primary health care is often neglected, which can lead to deaths from other causes. Indeed, participant 14 expressed that:

It’s classic to go into an emergency situation, but forget to provide primary health care, so people die of other things. We take care of the Ebola patients, and then we don’t take care of other patients

P14

Overall, participants explained that humanitarian work unfolds in a complex ethical landscape, where urgency often overshadows the equally critical need for long-term disease care.

E) Care versus security

Humanitarian NGOs often need to operate in situations that require them to determine how much risk is acceptable for humanitarian workers to take in order to provide care. This issue is acute for field team leaders who must balance operational tasks with safety concerns. Five participants brought up this issue.

For instance, one participant underscored the extreme risks involved in their work, noting that their organization faced severe threats, assassinations, and kidnappings:

We’ve had several assassinations [...], but also hostages [...]. We currently have someone who has been a hostage for five or ten years, so these are extremely serious cases

P2

Another participant discussed the conflict between the responsibility to protect one’s team and the imperative to meet the needs of the affected population:

It can be a conflict between the value of staff security, where you’re wanting to protect your own team, and the good thing of going out and trying to give a food distribution to someone, but it’s dangerous

P4

Similarly, participant 14 noted the tension between practicality and ethics in the tough choices humanitarian workers often have to make:

A major ethical issue, particularly as coordinator, is whether we are ensuring the safety of our staff versus meeting the needs of the population. There have been times when we’ve met people who’ve been in accidents on the road, and we’ve been told that we wouldn’t stop to help them if they had Ebola. You’re driving around in a car with the Red Cross logo on it, you have an accident and you drive right past it

P14

As reported by participant 3, ethical issues also extend to the personal sacrifices made by NGO workers, who must weigh their responsibilities to their families against their commitment to their mission, which adds another layer of complexity to the decisions about how much risk is justifiable in such perilous settings. Overall, participants noted the challenges of ethical issues faced by NGOs as they navigate the dual imperatives of providing care and ensuring staff safety.

2. Resource scarcity

The theme of resource scarcity encompasses various resource inadequacies that may arise in humanitarian work. We grouped these under the following ethical issues: A) lack of financial and material resources, B) lack of preparation, and C) lack of ethical resources (Table 4).

Table 4

**Ethical issues related to resource scarcity**

A) Lack of preparation

Four participants described their general lack of preparation for humanitarian work. As stated by participant 14: “There’s not enough preparation”. Specifically, they observed a significant gap between the predominantly theoretical training they received prior to their field experiences, and their actual needs. Such gaps often leave humanitarian workers without the appropriate strategies or knowledge necessary for effective operations. This can also lead to distress among workers and, at times, jeopardize the mission’s success.

For instance, one participant discussed the clash between ethical ideals and reality in the field:

That’s how I was trained, according to a certain code of ethics. And then we arrive [in the field], with very high standards in contexts totally different from ours [...]. So, there are clashes, with different capacities and resources

P1

Similarly, another participant mentioned that:

One of the biggest issues is […] the lack of training for practitioners. Either responders or researchers working […] try to deal with the ethical issues, [but] as a result of that [the lack of training] they’re often […] left off to deal with them on their own or to maybe talk about [them] informally

P3

Finally, one participant explained that knowing how to prioritize and distribute resources was not easy in practice:

[…] they know how to do food distribution, they know technically what are a good practice and a bad practice in a food distribution, but it is very troubling to them which group of people they should prioritize in this situation because of various factors that are not about nutrition. They’re about politics, access, capability, whatever

P4

A lack of practical preparation can leave humanitarian workers ill-equipped to handle ethical issues and operational challenges.

B) Lack of ethical resources

The lack of ethical resources described by participants include three different sub-categories: lack of a place to speak out (identified by six participants), lack of a clear ethical authority (three participants), and lack of standardized paths for decision-making (two participants).

First, some participants noted a significant gap in the availability of formal spaces dedicated to shared ethical reflection. Indeed, one participant noted the spontaneous emergence of such spaces within specific teams or under certain managers, but explained that these were not a standard feature across organizations:

Participant: [...] there’s a real need to open up spaces, spaces that don’t spontaneously exist, for shared ethical reflection, never alone, but in a group, to set up a deliberation group and a deliberation process.

Interviewer: Did you say that these are spaces that don’t currently exist?

Participant: They exist spontaneously in many places. They often exist on a team’s own initiative, from a manager, the team leader, etc., but I’d say at the ICRC or what I’ve seen in organizations [...] it doesn’t exist. So, it’s done in a sort of cobbled-together way, and when it’s done well, it’s great, but when it doesn’t exist, there’s always the risk of authoritarian drift

P2

Participant 5 further expressed that there were not more spaces to speak about ethics in academic settings than in the field:

[...] because I don’t belong to an organisation, I don’t have a place to speak. I tried to develop one at the [name of the university] when I worked there [...] but because humanitarian research and practice were not valued [there], it was never taken up. [...] So I wasn’t able to create that space [and] within the organisations where I worked, there wasn’t that space [...]

P5

Finally, one other participant noted that the consistent lack of designated spaces for ethical dialogue makes it difficult to foster a collective ethical environment:

Often we don’t have that much space to talk about it, and that, I think, is a problem, because I think everyone needs to talk, at least to be heard, to express themselves

P14

Second, the ambiguity concerning who holds ethical authority in decision-making processes was also identified by three participants. These participants expressed confusion over whether decisions should be made internally within a group, or if they should rely on external authorities or donors. Namely, such confusion is compounded by the absence of clear guidelines on who should make these ethical decisions, as mentioned by participant 5:

And so, when there are ethical difficulties within a vulnerable group, people often tend to say, “Who can solve this situation for us?” They won’t have the reflex to say: “We have the means; we can give ourselves the tools to resolve the situation.” So [they’ll] look for an ethical authority outside the group, and there’s a real confusion about who can make an ethical decision. Can we make it ourselves? Should we defer to someone else, should we defer to the funders? And the guidelines for ethical authority are very vague

P5

The issue also extends to communication of sensitive and culturally relevant decisions across different contexts and individuals:

You know, there are still questions about who decides and how decisions get made, and in particular how are delicate and difficult culturally sensitive issues [can be] communicated across contexts and across individuals, or among individuals

P6

Third, two participants found the lack of standardized procedures for ethical decision-making to be particularly problematic. Participant 12 described the difficulty in determining when decisions should be made independently or when higher-level consultation is necessary:

[…] the line between the point when I can decide independently for my staff or with my staff versus when I need to consult my bosses is sometimes grey. […] It’s an area that I’ve found complicated with [this NGO]. […] I’ve noticed that it’s very hierarchical and I’m not used to that. […] I wouldn’t say [this NGO] is formal, but there is this sense of like when you are deciding, you need to consult with the right people, and you need to keep the right people in the loop. But […] there’s also this sense of [not wanting] to bother these people with these basic questions if I don’t need to. […] It’s probably one of the most stressful things of my job to be honest, navigating, should I make this decision on my own or not

P12

Participant 1 noted the inconsistent and potentially inequitable decision-making process:

We really did decide on an ad hoc basis. Case by case. [...] Some cases yes, some no, depending on how you saw the situation. I thought it was a bit unequal. On what basis?

P1

Overall, participants underlined the lack of structured resources for ethical deliberation and authority, as well as a need for clearer and more consistent decision-making processes in organizational settings.

C) Lack of financial and material resources

One of the ethical issues most frequently arising in this study, and discussed by eight participants, was the continuous lack of financial and material resources. Given the enormous demands for humanitarian work, available resources often seem insufficient. Participants highlighted the ethical issues which such scarcity imposes.

For instance, as participant pointed out:

What was difficult from an ethical point of view was that, first of all, the quantity of international equipment was limited. It was never at full capacity

P1

Similarly, participant 2 mentioned the constraints not only of material resources but also of time.

The challenge of insufficient resources forces humanitarian workers to make tough ethical decisions. As participant 3 noted, this often involves deciding how to distribute the limited resources:

[…] insufficient resources to address the problems and the challenges that they face and so often we’ll have to make ethical decisions around what they can address and how do they address it and so on to meet the numerous challenges

P3

In fact, rationing and making allocation decisions was described by participant 4 as:

[…] one of the most profound areas is rationing, actually how we make decisions around the allocation of inevitably limited and probably insufficient resources

P4

To this point, participant 5 underscored the scale of the issues humanitarian workers encounter in the field compared to the scant resources to which they have access.

Finally, participant 6 reflected on how resource allocation issues arise almost systematically:

All of the stories would probably be quite different if there wasn’t scarcity of access to treatments or a scarcity of access to personal

P6

3. Political considerations

Under the theme of political considerations, we group the ethical issues that deal with NGOs, their decision-making structures, and the way they operate. These are political considerations because, although the issues addressed by participants involve specific individuals or management practices, in reality these issues refer to deeper social and ideological questions. This theme comprises three ethical issues: A) distance between organizational decisions and field practices, B) asymmetry between local workers and expatriates, and C) authoritarianism, racism, and theft by NGOs and partners (Table 5).

Table 5

**Ethical issues related to political considerations**

A) Distance between organizational decisions and field practices

In many NGOs a disconnect often exists between organizational decision-making centres and the realities faced by field workers. This gap, which was described by 7 participants, is highlighted by discrepancies between on-the-ground needs and the strategic decisions made at the headquarters, which are often remote from the intervention areas.

For instance, one participant, in discussing challenges related to medicine procurement policies with the NGO she worked for, highlighted the distance that can develop between policies and how things actually work in the field:

Treatments and medicines were not always ordered or available. As far as the mission was concerned, I was working as a Canadian expert at the operational centre, but for the NGO operational centre. At the Operations Centre in [name of city]. With them, they didn’t necessarily agree to buy medicines locally. It had to be of a certain quality, tested. When we could have found local medicines that have an impact on glycemia. You know, there’s a lot of work to be done in this area

P1

Another participant described how bureaucratic challenges can overlook pressing local needs:

I work in South Africa, and my grants are to support AIDS orphans. [...] When I arrive in the field, what I realize is [...] that there is one group that is even more vulnerable: the children who still have their parents, but whose parents have developed all the pathologies associated with AIDS. [...] And because of the nature of my funds, I don’t have the right to support these children, because technically, they’re not orphans

P5

To this point, participant 5 mentioned “ethical myopia”, which is the tendency of a person or an organization to impose their values on others or to assume that they share them, to discuss how some Western NGOs fail to engage with communities and thus hinder effective intervention and support:

[Ethical myopia is] very common in many Western NGOs, which don’t bother to carry out field consultations. So there’s a presumption that everyone agrees on fairness, that everyone agrees on the treatment of women, when that’s absolutely not the case. People haven’t checked what cultural mechanisms are in place on the ground

P5

One participant recounted instances of bureaucratic absurdities where field workers were unable to act in critical situations due to strict adherence to organizational rules:

There is bureaucratic nonsense [...] that is completely disconnected from the field and the needs of the field. I’ve seen cases where someone is literally dying, someone is dying between two street corners, and the [NGO] dude isn’t allowed to do anything for X reason that I don’t understand, that’s beyond me. The guy’s really pissed off, he wants to do something, but he can’t. If he does, he could lose his job

P11

Finally, one participant discussed the complexities of using potentially lower-quality medications when that is all that is available:

The tricky part is that I just got an email from my colleague that our headquarters has concerns about the quality of this morphine, because it’s pretty used in Bangladesh and they have actually said that we can’t use it because they felt like it’s not high-quality medication. […] I mean, it’s not my decision, but I sort of a question: is a slightly less quality medication better than none?

P12

Participants underscored the tension between centralized organizational decisions and the dynamic, often critical conditions encountered by humanitarian workers in the field. Such disconnections can impede effective response strategies.

B) Asymmetry between local workers and expatriates

Seven participants mentioned a disparity in the treatment of local humanitarian workers and expatriate humanitarian workers within NGOs. As mentioned by participant 3, this issue reveals that local staff often receive inferior treatment compared to their international counterparts, who are provided with better accommodations and vehicles, and better resources or security.

One participant noted a significant evolution in employment contracts and professional status, which historically exhibit almost unnoticed discrimination between local workers and expatriates:

An enormous amount of work has been done [...] on employment contracts and professional status involving discrimination that was almost unnoticed [...]. Local employees and expatriates. Expatriates from Switzerland, Canada, France, etc. or Africans who go to Asia or Asians who come to Africa and who have a status, at the time it was a contract from the head office and there were a certain number of rules that were not at all the same as for local employees, with a contract with the local delegation. But that’s changed. We now have a much more homogeneous system, which also allows us to move from one status to another

P2

Despite such improvements, power asymmetry remains a pervasive issue. Indeed, participant 6 explained that expatriates often reside in secure, gated compounds with personal transportation to work, in sharp contrast to that of local workers who may walk several kilometers to the same workplace. Similarly, participant 12 emphasized the privileges some workers have compared to others:

There are different layers of privileges there. Like this is why it’s complicated, like it’s not just that there’s the oppressed group and the privileged group in this context. There’s me that has the most privilege, you know like the international staff, even among us, there’s like some international staff who are African, we have a couple of Cameroonians and Kenyan colleagues who face discrimination in Bangladesh that I don’t experience. So even among international staff, there’s this dynamic. And we often discuss this, like “oh of course he got held up at the border way more than I did.” Like there’s an awareness of we don’t all have the same experiences. But they still have more access to resources and power than a lot of our national staff do. But then, within even a national staff, there’s people from Dakar, like our doctors or nurses who are brought in externally. They are more highly educated then our staff that are hired from the local community. They have higher salaries and all the stuff, but they often feel lack of security

P12

This participant described the layered privileges in humanitarian work, not only between locals and internationals but also among the internationals themselves.

Moreover, one participant noted that local personnel sometimes experienced greater risks without corresponding recognition or protection: “[...] it was only local staff doing the most dangerous things” (P14). The discrepancy extends beyond individual treatment to broader social implications, contributing to a class difference within the humanitarian field. In fact, one participant described what they saw as elitism at both the international and national levels:

There is a sort of humanitarian elite and national local levels as well and to become member of a humanitarian organization and you’re paid the biggest salary and government authorities and local people. You can end up in that situation of class difference

P4

This indicates that becoming a member of an NGO could significantly elevate one’s social and economic status, often creating stark status contrasts between humanitarian workers, as participant 13 explained:

There’s a big power difference of course between people. The humanitarian experts, I think, in general being much more flexible and, you know, have their security, etc. And people there, you know, like my health promotion team in Congo, there was the end of the mission and now I’m faithful, I remain in contact with these people, most of them don’t work anymore

P13

Overall, participants expressed that power differences and layers of privilege challenge the equity of treatment between local workers and expatriates in humanitarian work.

C) Authoritarianism, racism, and theft by NGOs and partners

We group under malpractice from NGOs and their partners those behaviours that are unprofessional or even illegal, including theft and corruption, racism and stigmatisation, and authoritarianism in decision-making processes. While it is not always clear who is to blame in the cases mentioned by participants, it is nevertheless clear that these cases are the result of poor professional practice and conceal some major problems.

First, with regards to theft and corruption, one participant talked about an “organized system” of medical supply theft:

For some years now, certain employees had been aware of a certain organized system of theft of medical equipment, but they were unable to denounce the situation. [...] I could see that the allocation of positions and promotions was arbitrary, both for us expatriates and for the national staff. If you’re friends with the project manager, he’s connected. Also, a lot of racism

P1

Another participant mentioned corruption in drug distribution:

[…] when we know that if we don’t have access to antiretrovirals, it can often be because of corruption on the part of certain organizations that will favour certain groups, even choosing not to distribute because it’s too much work. With several of my partners, even the NGOs in the field saw no problem [...] in perpetuating violence against women. Then we realize that the clinics are lying to us. This often happens, where there’s a kind of reappropriation of goods that should normally be offered free of charge. The same goes for food distribution in war zones

P5

Yet another participant explained how corruption underlies jobs attributions in NGOs:

If there’s funding to pay a street worker, it’s likely that, unfortunately, the person who’s going to get the job won’t be the person […] who believes in it and wants it, it’ll be the person with the most influence and the best contacts, who may be completely useless at street intervention, but that’s the person who’s going to get the salary because the system over there will favour that, and we’re still talking about corruption and abuse of power

P8

Second, participants also pointed to racism and stigma within NGO operations. As participant 4 noted: “Industrious [discrimination], yeah, racism, stigmatisation, yes, in your own organisation” (P4). Similarly, participant 6 described power imbalances that reflect systemic racism and which were visible in the leadership structure of most organizations:

[Racism] show itself out quite clearly in the power imbalances. Just look at leadership in most organization, and I think you’ll see that there’s still stigma and racism associated with how the organizations are

P6

Third, authoritative decision-making styles of NGOs was also criticized by participants. Namely, participant 2 expressed that such “authoritarianism of decision-making” was linked to performance-focused management, and which could have dire consequences for field work:

[...] the question of authoritarianism [...] is very strong today. [...] It’s also linked to performance-based management methods and that sort of thing. [...] Authoritarianism in decision-making, within the same organization [...] if we haven’t had a real ethical debate, people soon realize that it’s difficult and that it may lead to disagreements, so we’re in a dilemma. If you don’t have the space to discuss it, you end up with a radicalized group. [...] You have decisions that are made, but which are not supported and which, in a hidden way, people will do a little differently from what they are asked to do. There’ll be double talk, there’ll be reports that don’t correspond to reality, there’ll be practices that are a little hidden and then, […] you’ll have burnouts, people slamming the door, crises in teams, all that, it happens. These are things we’ve come across

P2

However, one participant considered that a certain degree of authority was inevitable, and even beneficial:

In [this NGO], there’s a leader, a boss, a big boss. [...] But sometimes the way he manages things borders on dictatorship. But even for me, who often has trouble with authority, I’ve never had a problem with him because I trust him, I trust the man, I trust his profession and his decisions. [...] It’s not fair, but I can’t think of a better way to make it effective

P11

Finally, one participant described how problems like theft, abuse, and harassment were often overlooked in smaller organizations due to internal alliances and self-protection among staff, resulting, as seen above, in ethical silence:

Another ethical issue [...] is very frequent. When there are internal problems, we know about them, but we can’t talk about them. That’s not acceptable. Situations of theft, abuse, psychological or sexual harassment, and let’s keep it that way. [This NGO], which I know a lot more about, is a small organization. People protect each other. [...] What I’m talking about are problems that local people experience all the time

P14

Overall, participants emphasized that misconduct within NGOs can encompass various forms of unprofessional and illegal behaviour, ranging from corruption and theft to racism and authoritative decision-making.

4. Neocolonialism

Finally, the theme of neocolonialism brings together ethical issues of an ideological nature that permeate organizations and their decision-making processes. “Neocolonialism” designates here a form of domination where, although not overtly colonizing, Western white persons perpetuate an ideological superiority over non-white persons. This dynamic mirrors historical colonialism, where colonizers sought to conquer peoples who they deemed lesser, inferior, or primitive through a lens of white supremacy. In contemporary settings, this manifests as the monopolization of knowledge and power by white persons, implicitly reinforcing the idea that non-white individuals are inherently inferior or incapable (39,40). This continuity of supremacist logic from old colonial structures to current socio-political interactions is why we discuss the issues in this section in terms of “neocolonialism.” Under this theme, we group the following ethical issues identified by participants: paternalism, myopia, and white saviour complex, white people controlling decision-making positions, and power imbalance between NGOs and local governments (Table 6).

Table 6

**Ethical issues related to neocolonialism**

A) Paternalism, myopia, and white saviour complex

This issue was raised by twelve participants and refers generally to the often-paternalistic attitudes exhibited by Western humanitarians. Such humanitarian workers often arrive in crisis regions assuming a managerial role without adequately understanding local dynamics, expertise, or cultural norms. This approach not only results in a lack of sensitivity to local realities but also fosters ethical and cultural myopia, undermining the potential for effective collaboration.

For instance, participant 2 noted the inherent danger of paternalism when Western agencies deliver aid in crises, emphasizing the ethical issues that can arise when local initiatives and capacities are overlooked. This is compounded when organizations fail to recognize existing local systems, potentially exacerbating ethical issues, as mentioned by participant 3:

I think that sometimes humanitarian responses can undermine local initiatives and local capacity development. If a humanitarian organisation goes in thinking there is no system there, it just might overwhelm whatever pre-existing and that could create ethical problems through the blindness to realizing that people have some of these abilities

P3

Similarly, one participant mentioned the fact that some organizations focus narrowly on specific treatments without considering broader community needs, which amounts to ethical myopia:

So, ethical myopia definitely arises in vertical programming, where an organization sends somebody in to do expressly one kind of treatment. And then in some of the perceptions research that we’ve seen, the community says: “well you know, we’re really grateful that you came to treat the main injustice, but actually what was really a big issue in our community is something like kala-azar,” which is one of the examples that did come up in the literature. So, we’re glad that the organization is here, we would wish that you would be more responsive to our priorities instead of just sending what you think is what we need

P6

The imposition of Western values can also manifest in discriminatory practices in the field. For instance, participant 5 described a case of unequal service provision:

A large international NGO that receives funding from the UN, [...] but the way they do their work in the field is to tell disabled people: “You’ll only have access to services if you convert to Christianity.” [...] So there’s a kind of tacit inequality because of religion, gender or the clan you belong to

P5

The perception of Westerners as benefactors merely distributing aid without substantial engagement further complicates relationships. For instance, one participant expressed that there seemed to be a culture of expecting Westerners to take charge when arriving in the field, or having locals set their own needs aside to conform to what they felt Westerners would want:

When we show up in Haiti to meet our fellow street workers, they have the unfortunate cultural reflex, I think, of looking at us and saying: “Tell us what to do, you [Westerners].” We’re always saying that they’ve been like that for 300 years, in this culture where the white man comes in and says: “Do this, this, this and do it like that,” and we’re always saying: “Tell us what you want and what you need,” and unfortunately we realize that sometimes, as we experienced in Guatemala too, we always had the impression that they were telling us what we wanted to hear. Don’t tell me what I want to hear, tell me what you want. That takes a lot of time, and it really takes the solid foundations of a trusting relationship for the person to trust you enough to dare tell you what they want and what they think

P8

Further, another participant described how monetary donations, though well-intentioned, did not contribute significantly to sustainable development and might reinforce stereotypes of Westerners as wealthy outsiders:

Whether you come to see their village where they live and just drop in to do your business and leave, it’s not necessarily helpful [...]. In [name of region], they collected money and we went there to give them things. But apart from that, we didn’t do much. [...] It doesn’t necessarily give a good image either, in the sense that there are a lot of people who think: “Oh well, we’re white people, we come to give money and then we leave.” In the sense that after that, people wonder why we’re seen as rich or whatever

P7

To that point, participant 8 even compared Western workers’ behaviour to “Santa Claus” and criticized the dispensing gifts and leaving shortly after as distorting perceptions and expectations:

It’s this sort of habit of the workers, who, before leaving, would go to the local shopping mall and buy a whole bunch of toys, crayons, stickers, all the things kids might like. Then they’d play Santa Claus for a while, and on the last day before they left, they’d start handing out presents to everyone. For me, this raised questions and ethical issues, because once again, it really distorted children’s perceptions. It got to the point where we’d been there for [some days] and then some of the kids would ask us: “When you leave, what are you going to give me?” Damn, I’m here for four months, you can’t wait for me to leave because you know I’m going to give you a present when I go. Before we left, we bought things that we gave to the school, school equipment that was used at the school. We didn’t give anything to anyone, we were the boring volunteers. We may have hurt some children’s feelings, but it doesn’t work to have this sort of perception that we just turned up and were like Santa Clauses

P8

Participants highlighted the necessity for Western humanitarian efforts to engage more deeply and respectfully with local communities, prioritizing genuine collaboration and responsiveness to local needs over the imposition of external solutions.

B) Expatriates controlling decision-making positions

Three participants pointed to a prevailing trend within NGO operations where individuals from the Global North — often with less experience — predominantly occupy leadership and decision-making roles. This dynamic may result in the oversight of local or more seasoned colleagues who may possess greater expertise, local knowledge, and cultural understanding.

For instance, one participant noted the disproportionate amount of power and respect granted to individuals from the Western world or the Global North:

[…] a lot of power and authority is placed in the Westerner or the person from the Global North, who might come in with very little experience compared to what the local practitioners have. But they’re treated as, you know, so much more than that, given so much more respect just because of the colour of their skin or their accent or even the badge that they’re wearing

P6

Another participant shared a personal account, expressing discomfort with the authority they held as a relatively inexperienced white Canadian nurse managing a hospital:

[…] after my first mission with [this NGO, I felt] a real discomfort [about being] a very inexperienced white Canadian nurse who was the manager of this hospital, managing, you know, 50-year-old men who have been there since 20 years in that context. And I felt very, very uncomfortable with that dynamic, like the authority that I had just by virtue of what, I don’t know exactly

P12

Yet another participant pointed out that white Western expatriates often assumed team leadership roles shortly after completing their training, despite lacking on-the-ground experience:

You know, expatriates, [...] Westerners, whites, who arrive, who have no knowledge of the field, they’re on their first mission, they’ve just finished their training a year ago and they’re in charge of teams. But why? Why are they all team leaders? Well, that’s beginning to change, but it’s still happening [...] power relations, it doesn’t make sense [...]. To perpetuate that in countries [...] with a history of colonization

P14

C) Power imbalance between NGOs and local governments

Power imbalances often manifest due to the political and economic authority that NGOs wield over local entities. Six participants highlighted this issue, explaining how such imbalances affect ethical practices and local perceptions. For instance, one participant noted that individuals in areas targeted by research might feel coerced into participating for fear of losing assistance on critical issues like visa applications or protection:

[…] around the research area somebody might be asked about being involved in research and they may be really fearful that if they don’t agree to be a participant in the research that they might not get help to get a visa or protection. So that would be a way that somebody might stay silent about ethical concerns that they might have for being a research participant, among other fears

P3

Another participant discussed the broader concept of “humanitarian power,” suggesting that many involved in humanitarian efforts may not fully grasp their influence over local communities and authorities:

I do believe in the notion of humanitarian power, and I think a lot of humanitarian agents just don’t understand how powerful they are in the face of local communities, sometimes local authorities. There are real asymmetries of power between people with hard power like guns and weapons and humanitarians who are largely soft power. There is power asymmetry between humanitarians and suffering people and between humanitarians and conflict parties, foreign parties and politicians and donors, [etc.]

P4

Further illustrating the complexity of NGO influence, another participant recounted the experience of a friend who volunteered in Peru through an initiative funded by a Canadian mining company:

[...] I also have a very good friend who went to Peru as a volunteer engaged by [this NGO] to work in a village where there was a Canadian mining company. In the end, it was the Canadian mining company that gave [this NGO] the money to send a Canadian volunteer to help the people with the economic and social problems directly caused by the impact of the mine’s installation in the area. It’s a chicken-and-egg situation. Why am I here? I’m here to make a good impression, to make the mining company look good, which is subsidizing a volunteer to be here, when we know that they make billions in profits every year, and that they have absolutely no concern for environmental standards in these countries

P8

This participant described a paradox, where the volunteer’s presence served to enhance the public image of the mining company, despite its ongoing extraction of vast profits and disregard for local environmental standards. Lastly, one participant touched on the substantial impact of NGOs in certain countries, raising questions about their accountability:

Because we’re taking up so much space, NGOs are taking up so much space in certain countries, they’re having such an impact that is it always the same thing? Are we just doing what we can without much accountability? It’s time to rethink the responsibility of organizations

P14

Power imbalances between NGOs and local governments significantly affect ethical practices, local perceptions, and raise concerns about accountability and coercion in humanitarian efforts.

DISCUSSION

The purpose of this study was to document the perceptions and experiences of diverse humanitarian workers, ethics experts, and NGO members regarding ethical issues in humanitarian work. The interviews revealed a complex ethical landscape characterized by value-based tensions, resource scarcity, political considerations, and neo-colonialism. Below, we present a comparison between our findings and previous literature, a philosophical reflection on humanitarian work and structural injustices, and an overview of the study’s strengths and limitations.

Comparison with literature

Prior empirical literature and interviews with the participants of our study highlight similar ethical issues concerning resource scarcity and allocation, corruption, cultural concerns, risks for workers, power imbalances, and long-term care and sustainability. Indeed, both prior literature and our study participants discuss the challenges of managing scarce resources effectively and ethically in the face of extensive needs. While the literature emphasizes the difficulties in prioritizing aid and managing scarce resources, often leading to tough decisions about who receives limited resources (16-20), our participants express that humanitarian workers often face a lack of preparation, lack financial and material resources, and lack ethical guidance, all of which exacerbate the issues pertaining to resource allocation and ethical decision-making in the field.

Further, issues pertaining to corruption and professionalism were highlighted for their impact on the integrity and effectiveness of humanitarian work. Prior empirical literature has explained how corruption can undermine humanitarian efforts, with improper behaviours of workers compromising aid integrity (16,17). Similarly, our participants discussed the ethical issues arising from the need to sometimes collaborate with local authorities or criminal organizations to deliver essential care. This could involve navigating governmental corruption, disproportionate budget allocations, and the ethical implications of engaging with armed groups.

Cultural concerns and operational challenges are also a source of ethical issues, in both the reviewed literature and our interviews. If the reviewed empirical literature discusses the need for humanitarian workers to navigate operational hurdles and cultural differences while managing their ethical implications in high-risk settings (17,22,26), our participants went deeper into specific conflicts, such as intercultural value clashes, the tension between respecting local customs and adhering to professional ethics, and the challenges of addressing unacceptable practices while maintaining respect for local cultures.

Speaking of risks and tensions, the prior literature we reviewed described the ethical issues faced by healthcare workers in conflict zones, including direct attacks on facilities, border closures, and the psychological burdens of making life-and-death decisions (18,22). Our participants echoed such concerns by highlighting the extreme risks, threats, and sacrifices at times involved in their work, and the ethical complexities of ensuring staff safety while meeting the needs of affected populations.

Power imbalances were identified as a significant ethical issue, with prior literature discussing the importance of managing influence and avoiding colonial dynamics in humanitarian interventions (17,27). To this point, participants addressed systemic issues like control over decision-making, racism, and the impact of these imbalances on local communities. They highlighted the unethical practices of NGOs and partners, such as theft, corruption, and authoritative decision-making, and the significant impact of NGO influence on local governments and communities.

Lastly, ethical issues concerning the sustainability and long-term impact of humanitarian work were discussed, focusing on the balance between immediate emergency interventions and sustainable healthcare solutions. Prior literature emphasizes the need for early planning for project closure, engaging with donors and stakeholders, and ensuring the sustainability of benefits post-closure (28,29). Participants highlighted ethical issues pertaining to having to prioritize between emergency and long-term care, noting the challenges of managing chronic diseases and the neglect of primary health care in emergency situations. They stressed the importance of addressing both urgent needs and long-term health support to ensure comprehensive and sustainable humanitarian interventions.

Beyond these similarities, our study’s multi-perspective approach surfaced two critical ethical issues largely absent from the prior empirical literature that we reviewed: ethical silence and neocolonialism.

The identification of ethical silence, by participants who described the reluctance of workers to speak out against unethical practices due to fears of repercussions, job loss, and negative judgments, suggests a systemic barrier to accountability within humanitarian organizations. This silence stems from a combination of fear, external pressures, and problematic organizational cultures that discourage transparency and accountability. While prior studies have noted emotional stress and burnout, they have not empirically documented the organizational pressures that compel workers to remain silent about various issues. Perhaps the inclusion of diverse humanitarian actors with varied perspectives helped gain a vantage point from which to see this phenomenon not just as an individual choice, but as an organizational and cultural problem. This finding suggests that without formal mechanisms to break this silence, many other ethical issues may remain hidden and unaddressed.

Neocolonialism, while addressed in terms of power imbalances and corruption in previous literature, was discussed by participants as the perpetuation of paternalism, the white saviour complex, and Western domination in decision-making. Participants noted that Western humanitarians often assumed managerial roles without understanding local dynamics, fostering cultural insensitivity and undermining collaboration. They also highlighted the disproportionate control of leadership positions by white individuals, which overlooks the expertise of non-white colleagues and reinforces power imbalances. The substantial influence of NGOs over local governments further exacerbates these ethical issues, raising concerns about coercion, accountability, and the effectiveness of humanitarian efforts. The significance here is that our study provides empirical evidence that such power imbalances are not just historical vestiges but instead active, ongoing structures that can perpetuate a sense of Western superiority. This finding challenges the humanitarian sector to confront not just its practices, but also the deeply ingrained colonial logic that continues to shape them. Participants stressed the need for genuine engagement and responsiveness to local needs over the imposition of external solutions.

Humanitarian work and structural injustices

Our findings, particularly those related to neocolonialism and the asymmetries between local and expatriate workers, strongly suggest that humanitarian work is deeply affected by structural systems of oppression. To better interpret and articulate the dynamics described by the participants, a theoretical lens can be instructive. The “coin model of privilege,” developed by Stephanie A. Nixon (42), serves as a useful heuristic tool for this purpose: it is a framework that can help make sense of what the participants. Indeed, Nixon explains that societal structures inherently provide privileges (unearned advantages) to some while disadvantaging others. To illustrate, she invites seeing such privileges and disadvantages as a coin with two sides: privilege on top and oppression on the bottom. With this metaphor, she underscores that addressing structural inequities requires not only aiding disadvantaged groups but also dismantling the systems that create these disparities and inequalities in the first place. The fact that those on the top of the coin often do not realize their unearned privileges leads to a lack of awareness that perpetuates inequality, or a form of “willful hermeneutical ignorance” (i.e., the situation in which marginalized knowers develop suitable epistemic resources to […] explain their experiences[,] but […] dominantly situated knowers willfully refuse to acknowledge these […] resources” by ignoring, minimizing, mocking, or disregarding their importance (43,44). This invisibility of privilege maintains the status quo, as privileged groups may (un)consciously reinforce systemic injustices. Seeking to dismantling privileges and oppression, and to work against their invisibility requires “critical allyship”, a process which, for Nixon, involves privileged groups recognizing their role in these systems, learning from marginalized groups, and actively working to dismantle oppressive structures (42).

In the context of humanitarian work, Nixon’s model can help illuminate the root causes of the power imbalances and neocolonial attitudes that participants identified. Humanitarian organizations, often led by expatriates from Western countries, may unconsciously perpetuate neo-colonial practices and fail to effectively address local needs. Recognizing and addressing these structural injustices is crucial for creating more equitable and effective humanitarian interventions. Indeed, our study reveals several instances where structural injustices and the invisibility of privilege affected humanitarian work. Participants noted the disparity in treatment between local workers and expatriates, namely instances where expatriate workers received better accommodations, resources, and security. This aligns with Nixon’s point about the unearned privileges held by those at the top of the coin, often leading to inequitable practices within organizations. Specifically, one participant described the discomfort of being a relatively inexperienced white Canadian nurse managing a hospital and overseeing experienced local staff. This is an example of differentially situated power dynamics, potentially fueled by privilege, where expatriates, despite their lack of experience, hold authoritative positions due to systemic biases. Additionally, participants highlighted ethical silence, where humanitarian workers refrain from reporting corruption or questionable practices due to fear of personal consequences. Such silence may in truth perpetuate existing (potentially oppressive) power structures and contribute to the invisibility of privilege, where those in positions of power may not recognize or challenge the systemic issues at play.

Nixon’s coin model may be an interesting tool to develop a language aimed at better identifying and naming the structural injustices in humanitarian work, and to see that structural injustices involve more than just providing aid. Further, the model encourages critical examination of the power dynamics within humanitarian organizations and a commitment to dismantling the systemic inequities that perpetuate these ethical issues. Nixon’s approach could help develop more just and effective humanitarian practices, benefiting both workers and the communities they help.

Strengths and limitations

In terms of strengths, not only does this study enhance empirical research of ethical issues in humanitarian work, which has predominantly been theoretical (5,14), it also engages with diverse perspectives, including those of humanitarian workers, NGO members, and humanitarian ethics experts, facilitating a rich, nuanced, and triangulated understanding. Additionally, the impartiality of the research team, which specializes in (fundamental and practical) ethics without a background in humanitarian work, was complemented by the richness of the experiences shared by the participants involved, which was deemed significant. However, the study has limitations, including a lack of perspectives from humanitarian workers currently affected by the issues on the ground, which might render the developed portrait somewhat incomplete. Specifically, we see it as a limitation that the sample did not include national staff of NGOs, particularly since the results emphasize issues that are likely to be perceived differently by locally hired humanitarian workers. Moreover, despite achieving data saturation, the sample size remains small, and the transferability of this research is variable or limited.

CONCLUSION

This study aimed to empirically document the perceptions and experiences of diverse humanitarian workers, NGO members, and humanitarian ethics experts regarding ethical issues in humanitarian work. The participant interviews highlighted four categories of ethical issues: value-based tensions, resource scarcity, political considerations, and neo-colonialism. The category of value-based tensions encompassed ethical issues involving intercultural conflicts, balancing care with security and collaboration, addressing emergency versus long-term care, and navigating ethical silence. Resource scarcity included issues such as a lack of financial and material resources, insufficient preparation, and inadequate ethical resources, all of which contributing to operational difficulties. The category of political considerations highlighted ethical issues related to NGO operations, including the disconnect between organizational decisions and field practices, the unequal treatment of local workers and expatriates, and instances of authoritarianism, racism, and corruption within NGOs and their partners. And ethical issues pertaining to neocolonialism highlighted how Western ideologies and power dynamics persist in humanitarian organizations, manifesting in issues like paternalism, control of decision-making by white individuals, and power imbalances between NGOs and local governments, perpetuating a sense of Western superiority over non-white individuals. As well, having identified neocolonialism as a key ethical issue in this study (undiscussed in prior empirical literature reviewed), we proposed a reflection on structural injustices and the need for critical allyship to address systemic inequities in humanitarian work.

This study is likely to have implications for research, teaching, and practice. Documenting the various perceptions of ethical issues faced by various humanitarian actors represents a contribution to the research and literature on humanitarian ethics. While literature on ethical issues arising in humanitarian work is predominantly theoretical, empirical research on this topic is ever-growing. Such research may subsequently inform the training and education received by humanitarian workers confronted with these issues, equipping them with the ability to identify, label, and potentially respond to such issues in practice more effectively. Considering the insights articulated by participants, it may be beneficial to incorporate formal spaces for ethical deliberation and the resolution of discrepancies between local and expatriate workers into humanitarian work. Indeed, the interviews conducted revealed the crucial importance of addressing ethical issues once they are identified. While this topic was only briefly touched upon by some participants, it merits further attention in future research.

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