S3-1_Nawaraj Upadhaya

Ethical issues in conducing health research in
conflict setting?
• Ethical dilemmas of Dr.P
• Treating injuries vs conducting
research
• Children as subjects
• Research feasibility
• Interacting with authorities
• Ethical challenges faced by field staff
• What can be done?
• Conclusion
Nawaraj Upadhaya, PhD
1 December, 2023
Ethical dilemmas of Dr. P and his team
• Dr. P is a physician and researcher from an East
African country.
• Dr. P works for an International NGO and provides
health services from the regional hospital located in
conflict zone.
• Dr. P and colleagues consider researching the
prevalence of HIV/AIDS and mental health among
children in the region and whether and to what extent
current policies address their needs.
Ethical dilemmas of Dr. P and his team…
• Whether a child’s assent to participate in
research or an adult relative’s consent to
enroll a child in research would be ethically
sufficient?
• There are chances of blood sample being lost
due to security incidents, roadblocks, and
ambushes.
• Test results are available only after 14 days.
Due to ongoing conflict there are challenges to
take the test result to the children’s house.
Ethical dilemmas of Dr. P and his team…
• If the children’s parents have been killed
and no guardian is present, it’s unclear
whether keeping newly orphaned children
in a research protocol is ethically
appropriate.
• it is ethically problematic to wait until
conflict ends to conduct research that could
lead to improvements.
Treating injuries vs. conducting research
• Ethical dilemmas often are portrayed as one option vs another,
especially when both options are ethical but prioritize different ethical
principles.
• Instead of viewing this case as an “either-or” dilemma in which the
clinicians should either care for patients or do research, a “both-and”
approach would allow the clinicians to strive both to care for patients
and to do research.
• Simply “export” health interventions shown to be effective in “stable”—
typically high-income—countries to conflict settings without evaluating
their effectiveness is also problematic.
Children as subjects
• Children’s participation in research requires additional
ethical scrutiny, especially in humanitarian and conflict
settings.
• The case of Dr P is further complicated by the fact that
children often are separated from their parents during
conflicts.
• Excluding them from research until they are old enough
to consent might deny them the benefits that such
research might generate.
• Allowing relatives to give consent for children’s
participation in research—might be reasonable,
especially if accepted in the region.
Research feasibility
• Humanitarian organizations and individuals working
in conflict zones might be overstretched and under-
resourced.
• The case of Dr P described challenges of
transporting samples, poor infrastructure, and
security issues.
• Before conducting clinical research in conflict zones,
assess the opportunities and the challenges
(including methodological, logistical, political, and
ethical challenges).
• Conducting unfeasible research has ethical
implications, since starting an unfeasible study
would waste resources.
Interacting with authorities
• Humanitarian organizations working in conflict settings
find themselves walking a tightrope between various
authorities.
• Getting the balance wrong can have fatal consequences
for those working for humanitarian organizations and
those they seek to help.
• The collection of information or biological samples
might be viewed with suspicion
• In the case of Dr P, the hospital could be attacked if it is
viewed as collaborating with one side or the other in
the conflict.
Ethical challenges faced by research staff
• The role conflicts (maintaining the objectivity of researchers while
responding to participant’s request for support)
• Feeling of guilt and moral distress (seeing acute situation but not being able
to address)
• “And sometimes while doing it [research] in the humanitarian crisis, person’s
need could be different. People are in crisis but without giving them anything
and asking them question might make them feel humiliated and stigmatised
which would result in even more stress in that person.” (NEP 16).
• High target for interviews in insecure working conditions (pressure of
finishing quickly but also maintaining methodological rigor)
What can be done (1)?
Protection of research staff from physical and emotional harm
• By making amendments to current ethical standards
• By improving the working conditions
• By addressing the power imbalances between researchers from high income
countries and researchers from low and middle income countries
• “There is a need for proper understanding (proper trainings) about ethics in
all levels. There is a need that researchers are well recognized by having
international standards for ethical considerations and approval” (AF17).
What can be done (2)?
Dissemination of preliminary findings with research participants
• “Yes this [no provision of validation of findings with research participants]
is also one ethical issue. What is the benefit for them?. Data is taken from
them and analyzed. They should know about it too because it is their
right. If like 10-20 people participated in research then they have that
right to know what they said and how their information was used” (NEP
15).
What can be done (3)?
Institutional development, capacity building and adequate financing of
national Institutional Review Boards (IRBs)
• “Well, I propose that there should be just a department for research with
assigned and dedicated people and well trained. There should be capacity
building and training of the staff that are reviewing proposals for ethics
approval, so there is improvement in their work” (SS59).
• “Likewise, ethics is not only limited to giving approvals. Follow-up is
necessary after that also. They have to follow whether the research is being
carried out in a same way it was submitted. These types of follow ups are not
done” (NEP30).
What can be done (4)
Deep ethical reflections through greater dialogue and discussion among
stakeholders
• “It will be good if there is close follow up in the field by the ethics
committee, to see the progress of our research and see if there are any
challenges. It could be done in different ways, such as a phone call”
(ET27).
Conclusion
• The ethical and practical challenges of conducting research in conflict settings
should not lead to it being abandoned.
• Creative approaches should be explored to manage time, find resources, and
adapt protocols as needed.
• Conducting research ethically in conflict settings requires significant effort and
flexibility, as well as sufficient resources and expertise.
• Research with children is an important way to address their needs (understood
holistically) with evidence-based interventions and policies.
• Viewing children as too vulnerable to participate in research might further
marginalize them and leave their treatment without supportive evidence.
Thank You !
• For more information, please contact me at:
nawaraj.upadhaya@healthright.org