Conceptualizing Ethical Issues of Humanitarian Work: Results From a Critical Literature Review

This article presents results of a critical review of the literature discussing the ethical issues arising in humanitarian work, following the method proposed by McCullough, Coverdale and Chervenak. Our aim was primarily to focus on how the ethical issues arising in humanitarian work are conceptualized within the literature we reviewed. We think that properly conceptualizing the ethical issues which humanitarian workers may face can provide avenues to better respond to them. We analysed 61 documents, as part of a literature review, which revealed that there truly is a need, amongst the authors and in Résumé Abstract Cet article présente les résultats d’une revue critique de la littérature traitant des questions éthiques soulevées par le travail humanitaire, suivant la méthode proposée par McCullough, Coverdale et Chervenak. Notre objectif était principalement de nous concentrer sur la façon dont les questions éthiques soulevées par le travail humanitaire sont conceptualisées dans la littérature que nous avons examinée. Nous pensons qu’une conceptualisation correcte des problèmes éthiques auxquels les travailleurs humanitaires peuvent être confrontés peut fournir des pistes pour mieux y répondre. Nous avons analysé 61 documents, dans le cadre de la revue de la littérature, qui révèlent qu’il existe réellement un besoin, chez les auteurs et dans le travail humanitaire, de discuter de l’éthique. En effet, même si seul un petit nombre d’auteurs définit explicitement les mots qu’ils utilisent pour parler d’éthique, la grande quantité de mots que nous avons découverts dans les documents semble suggérer des terrains vastes et riches sur lesquels aborder les questions éthiques. Nous pensons qu’il est bon que les questions éthiques du travail humanitaire soient de plus en plus abordées dans la littérature et qu’il serait pertinent que le vocabulaire utilisé par les auteurs soit employé et développé de manière encore plus rigoureuse, afin que leurs discussions soient plus précises, cohérentes, pertinentes, exhaustives et suffisantes. La revue de la littérature, ainsi que l’analyse qui en découle dans cet article, s’inscrit dans un projet plus large visant à proposer une manière de conceptualiser les enjeux éthiques du travail humanitaire en se basant sur les forces et les innovations de cette étude et d’autres. This article presents results of a critical review of the literature discussing the ethical issues arising in humanitarian work, following the method proposed by McCullough, Coverdale and Chervenak. Our aim was primarily to focus on how the ethical issues arising in humanitarian work are conceptualized within the literature we reviewed. We think that properly conceptualizing the ethical issues which humanitarian workers may face can provide avenues to better respond to them. We analysed 61 documents, as part of a literature review, which revealed that there truly is a need, amongst the authors and in humanitarian work, to discuss ethics. Indeed, even if only a small number of authors define explicitly the words they use to discuss ethics, the great quantity that we have uncovered in the documents seem to suggest vast and rich grounds upon which to address ethical issues. We believe it to be important that the ethical issues of humanitarian work are increasingly addressed in the literature and argue that it would be helpful for the vocabulary used by authors to be employed and developed even more rigorously, so that their discussions show more precision, coherence, relevance, exhaustiveness, and sufficiency. The review of the literature, as well as the resulting analysis in this article, is part of a broader project to suggest a way to conceptualize the ethical issues of humanitarian work based on the strengths and innovations of this and other studies. lack of appropriate concepts can hinder learning, interfere with memory block inferences, obstruct explanation, and perpetuate problems (1).


INTRODUCTION
Humanitarian work was historically understood to encompass immediate, rapid and short-term relief. In this article, we use the phrase "humanitarian work" to refer to any activity that has a humanitarian purpose. Some consider it important to distinguish humanitarian work according to its different categories and ways of dealing with the urgency to act, sometimes by calling it humanitarian medicine or development aid. We prefer to discuss humanitarian work in general, as we find it in the literature. Humanitarian work is ever transforming, particularly because of the increased numbers of reported natural disasters (earthquakes, floods, drought, etc.) and (human-made) complex emergencies. This in turn reinforces the need for long-term, elaborate and accurately monitored aid to affected populations and regions (2).
In fact, complex emergencies have become increasingly frequent since the early 1990s and require a lot of non-governmental organizatins (NGOs) to be involved (3). More specifically, a multitude of humanitarian actors, be they humanitarian workers in the field, local populations, local and foreign governments, or international (e.g., United Nations) or independent (International Committee of the Red Cross) organizations, are involved in the dynamics of humanitarian work in these complex emergencies. These emergencies are essentially crises that arise from a particularly unstable political context and are often characterized by armed conflicts, relocation of populations or gross lack of access to vital resources (food, medicines, shelter) (4). The crises in the Democratic Republic of the Congo, Afghanistan and Bosnia are notable examples of such human-induced crises. In Page 153 these contexts, the resources available to manage and improve unstable situations are often inadequate (5,6). Further, these crises at times require the help of several NGOs, thereby making effective coordination especially challenging, both between NGOs and with local and national governmental agents (7)(8)(9).
In this article, we define an ethical issue as a situation that may undermine, in part or in whole, the respect for at least one value or principle considered desirable (10). We understand that the authors of the documents we reviewed sometimes use other words to define the ethical concepts that they address. However, we use the term "ethical issues" as an encompassing concept to better situate the (at times) complex conceptualizations emerging from the literature. The ethical issues faced by humanitarian actors 1 are numerous, and can be both complex and persistent (11). Indeed, a significant number of authors note that humanitarian work carries its share of risks for workers, particularly because of the context in which they must operate (8,12,13). In fact, humanitarian actors often have to work under considerable pressure in contexts where resources are limited and needs are high (14)(15)(16).
For humanitarian actors to recognize the ethical issues they face and for resources to be put in place to help them, it is important that the issues be clearly conceptualized. This article addresses how the ethical issues arising in the context of humanitarian work are conceptualized in the literature. Our assumption is that clearly identifying, conceptualizing and analyzing an ethical issue can help people involved to better respond and maybe even contribute to resolving the situation. In other words, the aim of this research is to critically appraise how the authors interested in the ethics of humanitarian work discuss these issues. Ultimately, our study aims to better equip humanitarian actors to identify and address the ethical issues they may encounter and to contribute to greater clarity and precision in the analysis of ethical issues in humanitarian work. This paper is part of a broader project examining how ethical issues are addressed in different practical and theoretical fields, and considers, following previous research in the field of bioethics (17), that the conceptualization is likely to be complex, even contradictory.

RESEARCH METHODS
We conducted a critical review of the literature using the method developed by McCullough, Coverdale and Chervenak (18,19), because it is one of the only methods specifically designed to target and analyze ethical concepts. It proposes four steps to identify and critically evaluate the literature (see Figure 1).

Figure 1: The four steps of the critical literature review
Step 1: Formulate relevant research questions to conduct the literature review We identified six research questions to guide our review: (a) What are the ethical issues facing humanitarian actors? (b) What means are proposed to address these issues? (c) How are the ethical issues arising in humanitarian work conceptualized in the literature? (d) How are these concepts defined, if any? (e) What theoretical foundations do the authors use? (f) What typologies do the reviewed documents develop or discuss issues? This article provides answers to questions (c), (d), (e) and (f), that is, the questions interested in the conceptualization of ethical issues in humanitarian work. Owing to considerations of space and to the distinct nature of the reflections, the answers to the first two questions, (a) and (b), are the subject of a separate article. 1 We prefer to use the term humanitarian "actor", because (1) this word seems to us to be the most appropriate to describe the role moral agents play in humanitarian action and (2) because this word allows, in its use in research questions, to vary, according to the document in question, the viewpoint of the issues identified. In other words, we are both interested in the ethical issues arising in offering and receiving humanitarian assistance. We believe that the word "actor" in this context makes it possible to include as many ethical issues experienced in humanitarian work as possible, from the perspective of various actors.
Step 1 -Formulate relevant research questions to conduct the literature review Step 2 -Select keywords to identify relevant literature Step 3 -Extract and synthesize data from the selected literature to answer the research questions Step 4 -Critically assess the way ethical issues are conceptualized in the literature Step 2: Select keywords to identify relevant literature Using the questions developed in step 1, we identified relevant keywords to be employed in finding literature in various databases. The list of keywords was developed both in French and in English (see Table 1). We used both open and restricted access databases which were made available through the researchers' affiliation with the Université du Québec à Trois-Rivières (UQTR). The databases were selected for their easy access and because they seemed able to provide sufficient documents to conduct the review. We believe that in scanning a large number of databases we would be able to collect a significant number of documents. See Table 2 for a complete list of databases and search engines used, as well as the number of documents for each. To be included, a document had to be in either English or French, answer at least one of the research questions, and be accessible through the UQTR library system without subscription or additional fees. We did not exclude articles based on publication date since we wanted to obtain as much literature as possible. We included peer-reviewed articles, books and book chapters, and non-peer reviewed articles published in academic or professional journals.  Figure 2 shows the decisions that were made to exclude some of these documents due to their irrelevance or the fact that they were duplicates. It provides an overview of the main steps in the review that led to the conceptual analysis of the body of literature. In the end, we reviewed 61 documents that met all of the above-mentioned inclusion criteria. We extracted bibliometric information to describe the documents: we targeted the author's name, the type of document identified, the date of publication, the written language, the type of humanitarian work involved, and the country of origin. The literature review was undertaken from September to December 2018.

Figure 2: The main steps and reasons for exclusion from the literature review
Step 3: Extract and synthesize data from the selected literature to answer the research questions Using spreadsheet software, we designed a table to extract data from the documents so as to compile them synthetically. In addition, we produced a data extraction table for each of the documents (see attached model in Appendix 1). The table allowed us to extract relevant information from the documents and provided an overview of how the documents could be relevant to our study.

Step 4: Critically assess how ethical issues are conceptualized in the literature
We critically appraised the conceptualization of ethical issues identified in the literature. We considered whether ethical issues were or were not conceptualized, and the quality of conceptualization based on the following criteria: relevance, coherence, sufficiency, precision and exhaustiveness. We discuss below (Disussion) how we used each of these criteria.

Bibliometrics
All of the selected documents were published between 1993 and 2018. In addition, as Figure 3 shows, 72% (n=44) of the documents were published after 2008. Figure 3 also reflects an increase in publications on ethical issues of humanitarian work from 2002 onwards, while the literature prior to this year is less than 10% (n=6) of the literary corpus identified. Of note, 2010, 2012 and 2017 were key years for the publication of writings on this topic, with combined documents from these three years representing more than 30% (n=19) of all reviewed documents.  Of the seven (n=7) book chapters identified, 4 were written in French. On the other hand, the peer-reviewed articles were mostly written in English. Indeed, of the 75% of the total corpus of peer-reviewed articles, 93% (n=43) were in English, while 6% (n=3) were in French. Moreover, even if non-peer-reviewed publications constituted 13% (n=8) of all the documents identified, it is interesting to note that none was in French. Figure 5 presents the number of documents reviewed according to the general themes in humanitarian work there were the focus of authors. While there is much to critique about a sharp divide between humanitarian work as assistance and humanitarian work as development, noting that these two will at times overlap, the point here is to show the avenues through which the authors address ethical issues. Some focus on health and medicine or on conflicts and emergency crises while others deal mostly with developmental humanitarian work, and still others address ethical issues arising in humanitarian work in general. Again, the point is that all of these authors discuss ethical issues pertaining to humanitarian work.

Figure 5. General themes of humanitarian work
After analysis, we noted that the literature mostly -nearly 44% (n=27) -involved ethical issues pertaining to health or humanitarian medicine. In addition, a significant proportion of the literature focused on the ethical issues of humanitarian work in more general terms, accounting for 34% (n=21) of the texts identified. Finally, there were nine (n=9) documents dealing more with the issue of emergency in disaster situations requiring humanitarian work, while there were four (n=4) documents dealing with humanitarian developmental assistance. Although these two themes were in the minority they accounted for about 20% of the documents reviewed. Moreover, if 44% (n=27) of the texts reviewed addressed the ethical issues of humanitarian medicine, it should be noted that none of these texts were written in French. While the majority of the documents written in French were book chapters, 86% (n=6) of them were interested in the ethical issues of humanitarian work in general.

What concepts of ethical issues are used in the literature?
We identified in the documents the use of 29 different words or groups of words employed by the authors to name, describe or discuss concepts of ethical issues within the scope of humanitarian work. Most of these words were not explicitly defined. However, some could argue that at times implicit definitions were provided through contextualised use of the words by the authors. These words or groups of words were identified either in French or in English; here we present either the original English words or the translated-from-French English words in the present text. Table 3 shows the frequency with which these words were used in the texts. Column B presents words that recur in at least 7 documents, while column C presents words that recur in more than 15 documents. We found that on average authors use about 3 different words or concepts to address and discuss ethical issues pertaining to humanitarian work.
While some authors explicitly employ concepts related to ethics in order to discuss the ethical issues in humanitarian work, some managed to discuss ethics without explicitly using such words or expressions. Table 4, for instance, provides an overview of all the related words used in the documents and the authors that used them. Our analysis found that Buth (20), Cardozo (12), Chung (21), Harroff-Tavel (22), Landman (23), Meldrum (24), and Tarvydas (25) successfully discuss ethical issues in a manner pertinent to the present literature review while having not explicitly used in their texts any words specifically pertaining to ethics. (More will be said about the normative grounds upon which to do ethics in the Discussion).

How are these concepts defined?
We were also interested in the definitions used by the authors to describe the concepts with which they discuss ethical issues -these were either explicit or implicit definitions. An explicit definition is grounded in theory and relies mostly on previous writings or reliable sources to clarify the meaning of a word in a manner such as x = y. Such explicit definitions can be found directly in the documents. Table 5 compiles some of the explicit definitions we have gathered. However, even these definitions are contextualized and thus refer to specific fields, themes or contexts, which make for a more refined understanding of their usage by the authors.
While the literature review identified 61 documents that answered at least one of the research questions of this article, 11 definitions of words meant to refer to ethical issues could be found in 10 different documents. In other words, more than 15% of the authors have explicitly defined the concepts they use to discuss ethical issues arising in humanitarian work settings.
What is more, the definition that Slim (11) presents is both consistent with his previous work and unique in its presentation, insofar as it provides a definition of a specific set of words rather than simply an idea or a concept. (It should be noted that he is the only one to offer such a precise definition). Additionally, if the definitions found are not in any clear contradiction, it is argued that they do not seem to engage one another theoretically. Finally, all the definitions found come from literature published after 1997 with only two definitions stemming from texts published before 2012.

What are the normative foundations mobilized by the authors?
This section highlights the normative foundations upon which the authors discuss ethics. It should be noted that two documents dealing with a similar theme may be based upon disparate normative grounds. For example, in a context of disaster relief actions, Leider (40) grounds the foundations of ethical discussions in a duty to develop plans allowing for a better prevention of disasters, because "[f]ailure to plan undermines the duty to provide the best care", while Civaner (6) more directly bases Civaner (6) "Violations of rights and professional duties along with any ethical dilemmas were defined as ethical problems" (p.5) Problem Draper (65) "A shared understanding of what was meant by an ethical challenge was established either during the interview or immediately before it commenced. We took as our working definition that adopted by Schwartz et al. (2010): 'situations where either the HCPs [health care professionals) knew what they felt was the right thing to do but were somehow prevented from enacting it, or where "doing the right thing" also caused harm'." (p.8)

Challenge
Geale (7) "In certain situations, ethical dilemmas may involve choices between equally undesirable later motives or conflicting moral codes (Jenson, 1997, p. 8)." (p.447) Dilemma Geale (7) "Finally, applied ethics involves examination of specific controversial issues that require a moral interpretation or position." (p.446) (An issue is then to be understood as that which requires moral interpretation or positioning.)

Issue
Gotowiec (33) "The term "moral dilemma" is defined as a decision where any possible choice will conflict with an existing moral principle (Blackburn 1994). At times, tough or hellish choices can masquerade as moral dilemmas (Slim 1997). For the purpose of this article, the authors have operationalized the term "ethical challenges" to encompass situations faced when the HCPs perceived themselves to be confronted by decisions that called upon their ethical principles in a problematic manner. The term "dilemma" is used when referencing previous work that utilized this term." (p.2)

Dilemma / Challenge
Haver (8) "An ethical dilemma is a choice between two bad options, where different moral imperatives conflict with one another." (p.2) Dilemma Michael (42) "It seeks to contextualise some of the associated humanitarian issues and to raise questions about roles, responsibilities and ethics. We understand ethics to be a search for those values, virtues, and principles necessary for people to live together in peace, mutual respect, and justice and hence to have an important role to play in exploring the nature of humanitarian principles. These are examined with a view to shedding light, or at least shining a torch, in the direction of the issues that merit further consideration and discussion." (p.112)

Ethics / Issue
Remer ( Slim (11) "They [the persistent ethical challenges] tend to rise anew in every humanitarian operation and seem to be integral rather than occasional problems in humanitarian ethics. In some way, these challenges are the core ethical problems of humanitarian action. They cannot be solved once and for all but must be lived through again in each new operation, albeit differently configured with new actors and settings but essentially the same." (p.183) Persistent ethical problems discussions on ethical typologies already developed by other authors, namely Hunt (35) and Schwartz (47). Not surprisingly, some authors rely on theoretical foundations previously developed by other authors (7,33,46). Some are based on (explicitly or implicitly) identifiable philosophical theories, such as deontological ethics or consequentialism (8,46), while others authors base their ethical discussions on various codes of ethics governing humanitarian work (65,69). Still others conceive the morality of humanitarian actions according to their adherence or opposition to certain human values, such as justice or autonomy, and believe that actions are immoral if they violate such values (26,65,68,69). Finally, what seems significant within the documents analysed is the emphasis on context in the attribution of moral significance and the categorization of ethical issues (6,7,43). For example, in a context of urgency and severe lack of resources, a Kantian deontological ethics cannot truly address the need to care for one person and not for another. Concern for context in the categorization of ethical issues may allow for this.

Which typologies are discussed in these writings in order to conceptualize the issues?
Some authors discuss ethical issues arising within humanitarian work contexts so as to classify them in types (6,11,15,28,31,35,37,48,51,53). This classifying accounts for about 16% of all the documents analyzed. It should also be noted that this specific sort of conceptualization may come from various sources, as authors tend to build upon previous work (6,31,62). For instance, Civaner and colleaugues (6)

Analyzing how the ethical issues are conceptualized in the literature
In the this section, we discuss the way the authors of the documents reviewed address the ethical issues of humanitarian work. We assess this conceptualization using five criteria: relevance, coherence, sufficiency, precision and exhaustiveness. We use each criterion separately at first, defining how we use them and then employing them to address the quality of the conceptualizations found in the documents. Our approach is threefold: 1) to evaluate the conceptualizations of the documents individually; 2) to infer relations between documents based on their degree of adequacy with respect to the evaluation criteria used; and 3) to appraise the documents using each of the criteria. The way we use the criteria for each level of evaluation are roughly the same, but we endeavour to specify which level we are discussing so as to gain the most accurate, but also nuanced, analysis possible.

Relevance
A concept is relevant if it permits authors to address the matter at hand accurately. In other words, any word used by an author to discuss ethical issues in humanitarian work is relevant if it falls within the scope of or allows for a better understanding of its bearing within the scope of ethics.
It appears that the words used by the authors in the documents are relevant, as they are usually skillfully described, so as to capture the importance of their use in the ethical analysis provided by the authors reviewed. If, at times, ethical analysis can be loosely organised and focus on the ethics of humanitarian work in a general way, as is the case with Brauman (53) and Le Coconnier (57), it does not seem to follow that the disorganizing stems from the authors' uses of impertinent words. On the contrary, when appraising the writing styles of the authors reviewed, we notice negligible variations in relevance of the words used to discuss ethics in humanitarian work. In other words, if it does vary, it is not clear that this is because of the words used rather than because of the writing style of the author in question.
Globally, it is difficult to say whether the list of words identified in the documents is relevant or not. It would neither seem correct to say the conceptualizations are relevant, nor that they are not. If such a list of words might seem to call into question the relevance of the concepts used by the authors, it may in fact point to the relevance of having ethical discussions within and about humanitarian work.

Coherence
Also, deeply rooted in a sense of consistency, we see coherence as the degree to which the concepts used by the authors follow from one another logically and with completeness. In other words, we believe a concept to be coherent when all of its necessary components are addressed in a reasoned and sound fashion so that we can grasp it. Roughly speaking, that would invite us to ponder whether we understand what the authors discuss and the links they establish. Such concerns are intertwined with the contexts in which the words are employed. In the literature that we uncovered, coherent use of ethical concepts could entail, for example, the uses and distinctions of the pertinent concepts.
When considering the documents individually, it seems again that context has much to do with how coherently the authors use the words identified to discuss ethics in humanitarian work. For instance, both Moley (43) and Asgary (27) identified the word 'responsibility' to have some importance in dealing with ethics in humanitarian work. Whereas Asgary (27) uses responsibility to refer to a sort of caring duty and Moley (43) employs it to refer to the duties in dealing with human rights, both successfully use the term coherently through context. Furthermore, even though some authors conceptualize ethics using multiple words, it does not seem to follow that their analyses lack coherence. If one were to compare Draper (65), whom we have identified as using, and defining, only the word 'challenge', and Geale (7), whom we have identified as using the words 'issue', 'dilemma' and 'challenge', we could say that both these authors coherently conceptualise ethics in humanitarian work.
Overall, looking at the list of 29 words identified, it is interesting to note that some of these words are used more by some authors than others. This is the case for words such as 'issues' or 'dilemmas', for example. But can we infer some form of cross-document conceptual coherence stemming from such widespread use?

Sufficiency
Also important is the sufficiency of the words used by the authors to discuss ethics in humanitarian work. An author used sufficient words to discuss ethical issues if the understanding is facilitated by the word choice and number. Ethical concepts would thus by insufficient if their amount impaired understanding.
Some of the documents use a lot of different words to discuss ethical issues. This can potentially contribute to understanding, as it provides the reader with more synonyms in order to understand all the ethical issues raised by the authors. Saying things differently sometimes helps. On the other hand, too many words can be detrimental to understanding if they are not well defined and if the reader is unable to discern what is being said. It would not be right to say that there are too many words used in the documents; as shown in Table 5, at least 15 documents use four (n=4) words or less to discuss ethical issues. It would be rash to draw any conclusion about the impact of these word uses on the readers' understanding. However, it should be emphasized that while such a large number of different words per article may not necessarily help the reader's understanding, it does not necessarily hinder it either.
Moreover, if one compares a document such as Haver's (8), which uses four (n=4) different words or expressions to discuss ethical issues arising in humanitarian work, with a document such as Forsythe's (70), which uses only one (n=1) word, we find that it is not always necessary to use many words in order to discuss ethics in such contexts. Sometimes a single word or expression can suffice if it is well contextualized. Finally, a significant number of words or expressions are used by the authors in conceptualizing ethical issues in humanitarian work. While it is important to remain cautious or even to advise more concision in the face of such numbers, it does not appear to be necessary. Indeed, although the reading of the documents reviewed enabled us to gather 29 different words, this number does not seem to hinder the conceptual understanding developed by the authors. On the contrary, it seems to contribute to a theoretical richness that should be commended.

Precision
When we think of precision, we think of the degree of refinement to which authors aspire in distinguishing the concepts they use to address ethical issues. Precision facilitates distinctions between various occurrences of different concepts, and thus is closely linked with clarity in that a precise concept will also be intelligible. The authors employ ample precision in describing, discussing or engaging with the ethical issues of humanitarian work. Even if the words used by some authors are at times varied, conceptualization does not seem to be lacking. For instance, Schwartz (13) uses five different words to refer to ethical issues, but the precision with which these authors differentiate words from one another reveals the adequacy of their conceptualization.
When it comes to conceptualizing ethical issues in humanitarian work, precision may vary depending on the author. For example, where both Geale (7) and Gotowiec (33) define the term 'dilemma' in their texts, Geale's definition relies on a more precise definition in that it highlights the fact that a dilemma arises when a choice has to be made between two undesirable options or when moral codes are in conflict (see Table 5). But in this case, a precise definition may not be the best. It is not entirely certain that all ethical dilemmas in humanitarian work arise, for example, when two undesirable options emerge. Because it stresses the importance of the moral principle over the singular choice to be made, Gotowiec's definition, while less precise, allows for ethical dilemmas to be more broadly conceptualized, so as to include those involving a choice between two desirable things. Indeed, it emphasizes moral principle, not moral choice.
The documents are precise in that they draw both from previous literature dealing with humanitarian ethics and from a certain humanitarian context. This allows for a conceptualization that is on the one hand varied, since it employs many words and concepts, and precise, because it is applied to a certain humanitarian context, making comprehensive the ethical discussions in the documents.

Exhaustiveness
Lastly, we evaluate concepts to be exhaustive if they are thoroughly employed, presented and explained by the authors. An exhaustive ethical conceptualisation would entail a comprehensive and thorough explanation of the concepts used to discuss the ethical issues pertaining to humanitarian work.
Given that very few documents contain explicitly identifiable definitions, one might be tempted to believe that authors may be exhaustive in discussion, but less so when having to explain how they make such choices. However, this may not be a major problem because, as already discussed, some of these authors are exhaustive in their justifications when adhering closely to the contexts of enunciation. Moreover, it appears difficult, in light of the significant amount of words used by the authors, to know how the use of one particular term is justified or preferable to another, which is sometimes made even more difficult as such as justification may be overlooked by the authors.
While it is not clear that the documents reviewed lack exhaustiveness, it might be relevant to question the accuracy with which the words are used by the authors. Perhaps focusing on accuracy would help to understand how so many words can emerge from our analyses. In any case, what seems to dominate in the literature reviewed is an exhaustive use of words discussing ethical issues in humanitarian work.

Quality of the conceptualization as a whole
Comprehensively, what we have before us is a wide-ranging discussion concerning the ethics of humanitarian work that reflects 1) the need to discuss ethical issues in different facets of humanitarian work, and 2) the richness of the experiences, contexts and issues of humanitarian work. What emerge mainly are conceptualizations that are both oriented towards specific areas or themes and context. However, it does seem that the list of words we have identified creates a dilemma of its own. Either all those words truly are different individual concepts and they indeed show a profusion of words used to discuss ethics, or they are not different concepts but are used somewhat interchangeably to refer to similar things. The fact that this is hard to tell may prove problematic on a conceptual level. Nevertheless, context is important in how we understand the way issues are conceptualized, especially in the ethics of humanitarian work. If 1) a document provides multiple different words to discuss ethics, and 2) we understand how they refer to different contexts and uses, does it necessarily follow that the conceptualizations provided by the author are deficient? What needs to be highlighted here perhaps is the fact that the criteria we used to evaluate the conceptualizations were but only a tool aiming to describe the bigger picture, to understand 'issue' as an ethical concept as a whole, in a field where the bigger picture can only ever be seen from a smaller point of view.

Evaluating the typologies
Not many authors of the documents we reviewed propose typologies -in fact, only 18% did so. We found two main types of typologies or categorizations in the documents: original typologies and categorizations based on previous typologies. Notable typologies identified include those of Bell (52), Hunt (15,35,37,66), Schwartz (47) and Slim (11). Bell (52) proposes four (n=4) categories of dilemmas faced by humanitarian workers and Hunt (37) suggests a six-point categorization of ethical issues related to the use of information technologies in humanitarian medical care. We also note that the typologies of ethical issues developed by Hunt (35) and Schwartz (47) are among the sources most frequently cited by authors who propose categorizations based on existing typologies. It is important to note something about the typologies developed by these authors. Indeed, they mainly classify important themes emerging from their research concerning a certain specific domain of humanitarian work. While such themes are important and relevant, it must be qualified that they do not aim to encompass all the ethical issues of humanitarian work. For instance, if we were to apply such an understanding to workers other than HCPs, we might fall short of avenues of discussion. However, the uses authors make of the typologies developed by Hunt and Schwartz make evident their convenience, in that they are oriented towards the needs of humanitarian work to describe its own ethical issues. As such, they constitute major advances in the development of good conceptualisations of the ethical issues of humanitarian work. To that end, the work of Hunt (35) is taken up by Bhan (28) and Civaner (6), while that of Schwartz (47) is used by Civaner (6) and Fraser (31).
In addition, it is important to note and acknowledge the major contribution of Slim (11). Even though we have reviewed and analyzed only two chapters from his 2015 book Humanitarian Ethics, and although his focus is on the persistent ethical issues in humanitarian work, we find the typology he employs relevant and encompassing. He categorizes ethical issues in humanitarian work in such a way as to distinguish between ongoing (regular) issues and systemic issues. The ethical issues he addresses are persistent because they are continually present, despite changes in location and even if concrete steps are taken to counter them. Sometimes, certain contexts make persistent issues greater, but Slim argues that these issues are common to all humanitarian settings.
Such an effort to categorize systemic and persistent issues in humanitarian work raises the question of what would happen if it were coupled with more practical and context-specific categorization efforts, like those developed by Hunt (35) and Schwartz (47). While it is not yet clear how such a typology could work out, it seems appropriate to take note of the efforts made by some authors in this direction. These efforts may, for their part, testify to a need to document the ethical issues in humanitarian work. In this sense, a fruitful dialogue between the authors could be important in order to eventually achieve a common understanding of the issues, something that might benefit from a shared conceptualization of ethical issues.

EPISTEMIC HUMILITY: AN EQUILIBRIUM BETWEEN ANALYTICAL AND HERMENEUTICAL PERSPECTIVES
Among the major approaches commonly used by theorists in philosophy, we can highlight the analytical and hermeneutical approaches. The analytical approach, which is very widespread in Anglo-American philosophy, involves critically reasoning about a given question, checking the validity of the terms used and questioning the logic of the arguments presented. This is, in a way, the approach we have favoured in the conceptual analysis of the ethical issues identified in the documents reviewed. Nevertheless, there is also the hermeneutical approach, which is more popular among continental philosophy theorists and consists of an interpretative, often phenomenological, analysis of subjective experiences.
While at first we were tempted to adopt an analytical approach to evaluate the conceptualizations gathered from the documents reviewed, we realized soon enough just how such an approach may be limited in the context of humanitarian ethics. The definitions we uncovered are deeply rooted in the contexts of their uses by the authors. This is the case, for instance, with the definition of 'dilemma'. It can be said that a dilemma arises between two desirable choices (10). In humanitarian work, we regularly come across cases of dilemmas involving two undesirable options confronting the humanitarian worker. We have come to realize that a dialogue between two theoretical approaches may help us to understand the range of meaning that can be given to such experiences. Indeed, we realized that both perspectives benefit from communicating with each other. This led us to a posture of epistemic humility and to the realization that the two philosophical approaches can be complementary, especially when attempting to construct a typology of ethical issues.

STRENGTHS AND LIMITATIONS
The strength of this study lies in the fact that we analyzed a significant number of documents, collected from a large number of databases. Additionally, our reading and analysis of these documents was thorough and rigorous. The analysis used precise and sound philosophical and scientific criteria. Also, we tried to manage our cognitive biases, or at least to identify and be aware of them. Further, the cross-sectoral backgrounds of the research team brought about a singular richness to our study.
As a way of transitioning from the strengths of our study to its limitations, we wish to highlight a point concerning the importance of contexts and the possible violence arising in humanitarian settings. On the one hand, as we tried to make evident explicitly in the introduction, we sought to embrace a broad understanding of humanitarianism as a way to be able to grasp more wholly how the ethical issues arising in humanitarian work are conceptualised from a variety of viewpoints, methods and understandings. However, on the other hand, this appears to be a somewhat unfitting amalgam in that there exist many insurmountable differences between caring for others and dealing with armed violence, for instance. Additionally, we may have omitted some documents, namely because of their written language, the impossibility to find them (for free) in the databases, or the keywords that might have offered different results. Furthermore, we identified the themes to be discussed in the discussion somewhat arbitrarily, even though they emerged from documents. For example, the fact that we consider 'humanitarian development' as part of the study may be controversial for some, even though it still appears in the review, and despite the fact that the keyword 'development' was never used. Finally, some may consider it futile to conceptualize the ethical issues arising in humanitarian. We believe, however, that well-documented and well-understood concrete problems may support the humanitarian practice. In this sense, we believe that a good understanding of the ethical issues faced by humanitarian workers could lead to better solutions to these issues.

CONCLUSION
In this article, we presented and discussed the results of a critical literature review of documents focused on the ethical issues arising in humanitarian work. Our analysis of the 61 documents revealed that there is a need to discuss ethics amongst the authors and in humanitarian work more generally. Indeed, even if only a small number of authors define explicitly the words they use to discuss ethics, the great quantity of words that were isolated in the documents seem to suggest vast and rich grounds upon which to address ethical issues. It is good that ethical issues arising in humanitarian work are increasingly addressed in the literature. But further progress could be made if, for example, the vocabulary developed by authors were more accurate, so that their discussions showed more precision, coherence, relevance, exhaustiveness, and sufficiency. However, we do acknowledge that our evaluation criteria were but only one tool amongst many others. In the end, we commend the work of those authors who developed typologies and categorisations, namely Bell (52), Bhan (28), Civaner 6), Fraser (31), Hunt (15,35,37), Schwartz (47), Slim (11) and Vaux (50).
Finally, this study is likely to have practical implications. Particularly, it may help those interested in ethical issues arising in humanitarian contexts to be more aware of the importance of defining the concepts they use. And it may help humanitarian workers in expressing the ethical realities they experience. It would in this sense be relevant to meet with such individuals, particularly humanitarian workers and members of humanitarian organisations, to document their perceptions of the ethical issues arising from their work and to identify the words they use to describe these issues. Lastly, it would be relevant to develop a well-constructed theory to describe the ethical issues of humanitarian work.