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Principal Investigator: Leonard Rubenstein, Johns Hopkins


The study aimed to investigate the nature of ethical challenges experienced by humanitarian health organisations in Syria, where there is significant violence directed at civilians and especially towards health care providers/services.

The research sought to provide processes and mechanisms, as well as practical tools, to guide humanitarian health organisations through complex ethical challenges facing them in these settings. For example, when a hospital is attacked and cannot continue operations, is it better to rebuild at the same location or move to a safer one farther away—even when doing so may hinder access to health care for some individuals and communities?


The study conducted a literature review. This was followed by key informant interviews with organisation managers and front-line health workers holding a range of clinical and management positions within health organisations working in Syria.

The research investigated the challenges they had experienced in delivering health services in Syria, how the challenges affected their work, and the approaches they take to resolve them.

The researchers then conducted in-depth interviews with front-line health workers to learn of the challenges they face and how they sought to resolve them, Inter-organisational workshops were held to share initial findings and pilot test the ethical framework

Key Findings

  • Frequent ethical challenges arise for organisations working in conflict settings, and are particularly difficult when health workers and facilities are themselves subjected to violence that both puts them at severe risk but affects their obligations to serve communities in need
  • Humanitarian organisations can better address ethical challenges faced in conflict settings by establishing internal procedures and mechanisms and utilising existing tools to approach the challenges in a systematic way.
  • Organisations are encouraged to commit time and resources for addressing ethical challenges, including: the use of decision-making tools, organisation-wide training, and engaging

Key Outputs

  • An ethical framework, tool and guidelines to enable humanitarian health organisations to make ethically sound decisions concerning health care provision in situations where there is violence against health services.
  • Training materials to support humanitarian organisations incorporate the tool and guidelines into pre-departure trainings for health workers, apply them in field settings characterised by extreme violence, and monitor and evaluate them.
  • Results presented at a Global Health Cluster meeting and with humanitarian funders (including USAID and DFID).
  • Findings published in multiple articles and a book chapter.



Get an overview of this research study and its findings in this research snapshot.



Chapter Ethics Related

Ethical Challenges Among Humanitarian Organisations: Insights from the Response to the Syrian Conflict

Report Ethics Related

Reality Makes Our Decisions: Ethical Challenges in Humanitarian Health in Situations of Extreme Violence

Peer Reviewed Ethics Related

Challenges to ethical obligations and humanitarian principles in conflict settings: a systematic review

Guidance Ethics Related

Ethical Decision-Making in Humanitarian Health in Situations of Extreme Violence

Latest Updates

Recommendations to humanitarian organisations

Nov 2019

The team give an overview of their research study and outline the recommendations they have for humanitarian organisations working in settings of extreme violence.


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