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Introduction
Médecins Sans Frontières (MSF) is an independent medical humanitarian organisation working in over 70 countries. It has provided medical assistance for over 35 years to populations vulnerable through conflict, disease and inadequate health systems. Medical ethics define the starting point of the relationship between medical staff and patients. The organisation's charter and guiding documents state that 'MSF volunteers undertake to respect their professional code of ethics' 1 and 'MSF missions are carried out in the respect of the rules of medical ethics, in particular the duty to provide care without causing harm to either individuals or groups. Each person in danger will be assisted with humanity, impartiality and in respect of medical confidentiality.' 2 Despite the clarity of this vision and of many other guiding policies, the translation of ethical principles and policies into the reality of humanitarian assistance can be messy and complex.
The ethics of humanitarian interventions and of research in conflict settings 3-6 are much debated. However, less is known about the ethical dilemmas faced by medical humanitarian staff in their daily work. 7 8 Ethical dilemmas can be intensified in humanitarian contexts by insecure environments, lack of optimum care, language barriers, potentially heightened power discrepancies between care providers and patients, differing cultural values and perceptions of patients, communities and medical staff. Time constraints, stressful conditions and lack of familiarity with ethical frameworks can prevent reflection on these dilemmas, as can frustration that such reflection does not necessarily provide instant solutions. Lack of reflection, however, can be distressing for medical practitioners 7 8 and can reduce the quality of care.
Ethical reflection has a central role in MSF, and the organisation uses ethical frameworks to help with clinical and programmatic decisions as well as in deliberations over operational research. This desire for reflection has led to this paper; however, we do not wish to debate ethical frameworks here. Instead, we illustrate and discuss, with the guidance of a professional ethicist, some real ethical dilemmas facing MSF teams. Only by sharing and seeking guidance can MSF and similar actors make more thoughtful and appropriate decisions. Our aim in sharing these cases is to invite discussion and dialogue in the wider medical community working in crisis, conflict or with severe resource limitations. For...