A doctor in a rural hospital in northeast Africa works with one oxygen machine, choosing which current patients receive treatment and how to limit care so the generator-run machine is available for future, possibly sicker, patients.

A physiotherapist brings limited funds from Canada to Central America where she then must choose which disabled child will get a wheelchair and which will not.

A Canadian nurse working in a Caribbean hospital watches as staff turn away premature babies because limited resources require the care available be saved for newborns most likely to survive.

In many cases, local professionals entreat Canadians to take these stories home and tell people about the struggles.

A group of Canadian health care professionals providing support and treatment to thousands of people suffering the consequences of man-made and natural disasters recently approached McMaster University ethicist Lisa Schwartz with stories like these and concerns about the ethical dilemmas they face while undertaking humanitarian work.

Their stories led Schwartz and her multidisciplinary research team to undertake what is believed to be the first analysis of its kind: Ethics in Humanitarian Aid Work: Learning From the Narratives of Humanitarian Health Workers studies the ethical struggles faced by humanitarian health care workers around the world.

The study has recently been published in American Journal of Bioethics (AJOB) Primary Research and in Public Health Ethics

According to Schwartz, the ethical dilemmas faced by humanitarian workers frequently deter them from offering their skills overseas a second time. For some agencies it can mean that up to 50 per cent of their volunteers never return to fieldwork.

The sense of not being able to make (enough of a) difference as a health care professional threaded through the narratives, the study said. Respondents spoke of their awareness of how far short their care fell of peoples health needs, and sometimes lamented the mismatch between what they had to offer and what people needed.

An innovative new approach is needed to prepare health care professionals before they leave to work internationally, says Schwartz. To date, little ethical analysis has been made of challenges encountered by expatriate health care professionals in the field. The findings demonstrate a need to provide practical ethics support for humanitarian health care workers.

For their analysis, researchers listened to ethical dilemmas faced by 20 Canadian-trained health care professionals  some newly qualified, others with years of experience – who have provided care in acute disasters, conflict zones, given post-disaster and development assistance, and worked with extreme poverty in developing countries. They included physicians, nurses, nurse practitioners, physiotherapists, public health specialists, consultants, midwives and lab technicians who collectively took part in 33 missions to Africa, 15 to Asia, six to Central America, four to Eastern Europe and two to the Caribbean.

After analyzing their stories, researchers found four main ethical challenges: Scarce resources; dealing with long-standing political, social and commercial structures; restrictive policies and agendas of aid agencies; perceived norms about the various roles of health professionals and how they interact with each other.

Twelve medical students who have done international health electives were also interviewed. A presentation on the student data will be given at a conference in October.

The study is funded by the Canadian Institutes of Health Research (CIHR).

Schwartz is the Arnold L. Johnson Chair in Health Care Ethics and associate professor in the Department of Clinical Epidemiology and Biostatistics. The multidisciplinary team includes Chris Sinding, Matthew Hunt, Naomi Adelson, Jennifer Ranford and Sonya DeLaat, and two physicians with extensive experience in humanitarian work Laurie Elit and Lynda Redwood-Campbell.