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1 Introduction

The title of this chapter combines two notions that are unusual, at least at first sight: ‘macro-triage’ and ‘disaster planning’. With these notions our attention will be focused on the global context in which disasters happen. Rather than prioritising needs in the midst of a disaster, we also have to prioritise which disasters require what type of response. The idea is that rather than selecting disaster victims for help we also need to select disasters for major relief, and we have to determine what the short-term and long-term goals of international assistance are. This global perspective also implies that the focus of analysis will be on the normative context rather than on the ethical problems arising in the practices of disaster relief .

In order to have a better idea of the ethical considerations that might be relevant I will begin by exploring the panorama that is presented by the notions ‘macro’, ‘triage’ and ‘disaster planning’ . Clarifying these notions will prepare the stage for critical examination of the normative presuppositions that are already at work before events are identified as disasters. Similarly, the moral geography of humanitarian intervention is explored. The emergence of humanitarianism as the driving force for contemporary disaster relief has produced a normative context in which action and intervention is required to save lives, to protect populations and to relief suffering . However, the moral logic of this context should be critically analysed since it is prioritising compassion over human rights and justice .

2 The Panorama

2.1 Macro-perspective

The reference to ‘macro’ directs our focus onto the social background and conditions of events and cases. ‘Macro-ethics’ is a common, although recent notion in the field of engineering ethics (Herkert 2001; Son 2008) . More than healthcare ethics, engineering ethics is used to deal with a litany of disasters such as airplane crashes, gas-tank fires, and nuclear accidents. In the face of technological failures it is important to distinguish between individual responsibility and social or organisational responsibility.

However, in healthcare ethics a similar distinction is made, following Pellegrino’s suggestion that there are two modes of engagement between philosophy and medicine: philosophy in medicine, and philosophy of medicine (Pellegrino 1976) . The first mode refers to the application of the traditional tools of philosophy (critical reflection, dialectical reasoning, and asking first-order questions) to some medically defined problems. In this vein we can refer to ethics in healthcare as the application of the tools of ethics to the problems of health care. Similarly we can focus on the ethics in disaster management and in humanitarian aid . Bioethicists can serve a useful role within these practices, help to examine the ethical dilemmas in everyday activities and contribute to resolving the problems that are defined and identified as needing attention by the professionals in the field. Ironically, this mode of engagement has itself been labelled as the engineering model of bioethics since this approach to bioethics can primarily be regarded as a sophisticated technology to make a particular set of problems manageable and controllable (Ten Have 2004) .

Philosophy of medicine, on the other hand, examines the conceptual foundations, the ideologies and the ethos which pervade the medical realm. Medicine continuously generates philosophical issues in regard to its meaning, its nature, concepts, purposes and value to society. From a critical perspective the practical context of medicine is no longer taken for granted, but it is considered to be an object of further philosophical inquiry, transcending the narrower medical context itself and producing questions that are of wider significance to understanding ourselves. Analogously, the ethics of healthcare can be regarded as the critical analysis of the meaning of health care, its nature, concepts, purposes and values. Such analysis assumes that healthcare as a practical human activity has a trans-medical meaning with important implications for our self-understanding. This is exactly the ‘macro’-perspective that will be developed in this chapter. Rather than analysing the ethical questions that are arising within the contemporary framework of disaster relief and humanitarian aid efforts , the focus will be on the ethical questions that are associated with the framework itself. Even if our engagement with humanitarian aid seems a priori morally unquestionable, it cannot be taken for granted.

2.2 Triage

The second notion to highlight is ‘triage’ . This is a common concept in emergency medicine . In ordinary circumstances triage will classify the wounded so that they will receive optimum care. It implies decisions regarding the order of treatment based on the urgency of need. However, triage has nowadays become an essential component in disaster relief . Disasters are characterised as situations in which the number of casualties outweighs the abilities to provide healthcare (this is in fact the main characteristic of the American College of Emergency Physicians’ definition of medical disasters; see ACEP 2011). In these extraordinary circumstances triage implies that not all victims can be treated. In other words, triage or the need to prioritise is already included in the definition of a disaster.

However, there is no agreement on the ethical criteria to make such decisions (Petrini 2010; Chapter 4 of this volume). In ordinary triage the focus is on the interests of individual patients. In extraordinary circumstances, the focus is unclear; is it on survival of the greatest number of persons or on survival of persons who are most likely to survive? Even if principles are proposed to guide decisions to allocate scarce resources, it is difficult to see how they solve the ethical dilemmas; the proposed principles often present a checklist of moral points of view to take into account rather than decisional tools (Barnett et al. 2009) . Some even doubt whether triage itself is ethically justified. There is no evidence that triage in a disaster setting will achieve its goals of saving more lives; the current disaster triage schema may actually worsen outcomes (Sztajnkrycer et al. 2006) .

It is clear that both ordinary and extraordinary triage is operating at the level of micro-ethics , i.e. decision-making for individual persons. What do we mean, then, by ‘macro-triage’? In order to unravel its meaning we must identify the perspectives that are introduced with the notion of triage.

First, triage introduces the military discourse. The concept was developed in the battlefield by Baron Larrey, surgeon-in-chief of Napoleon’s armies. Larrey has been praised for his egalitarian approach; selection for treatment was based on individual need rather than military rank, nationality or social status. This did not imply that available resources were focused on the interests of the individual person in need. In fact the requirements of the war effort prevailed. This remains clear in current military directives. For example, the NATO Handbook of Emergency War Surgery identifies three groups of patients in thermonuclear warfare: those with minimal wounds and those with too extensive wounds will not be evacuated (they either continue as fighting soldiers or they die); only those with relatively simple injuries that require immediate surgery will be evacuated and treated. Here the focus of triage is ‘salvage value’: salvaging the greatest number of lives and limbs. The ultimate goal of triage is to return the greatest possible number of soldiers to combat (NATO 2011, p. 182). The same military rationale underlies the concept of minimum qualifications for survival (Lin and Anderson-Shaw 2009) . Saving individual lives is not important as such but only within a broader context.

Second, triage introduces a paternalistic discourse that restrains individual freedom and human rights for the sake of the public good or the well-being of the population as a whole. In the discourse of triage, basic values are not determined in a democratic process or public deliberation but they are decided by ‘authorities’ who take control of the events. Such control can be legally regulated. Emergencies as well as disasters are declared by legal action, and addressed with unconventional legal responses. But even then, decisions need to be made about what to legislate first, so that the term ‘legal triage’ has been introduced for the construction of a legal environment in which legitimate public responses are facilitated (Hodge 2006) .

The fact that the introduction of the notion ‘triage’ is associated with military and paternalistic discourses makes clear that a micro-perspective of allocating scarce resources and selecting victims for treatment is always guided by a macro-perspective. It is precisely this encompassing perspective and its ethical implications that we have to identify.

2.3 Disaster Planning

Disaster planning is an oxymoron that refers to new strategies that first have developed in the area of public health . What is meant here is disaster response planning. But instead of emphasising prevention, the focus is now on preparedness . The basic idea is that catastrophic events such as pandemics but also natural disasters cannot be prevented. However we know that one day or another we have to face them, so we need to be prepared. Over the last decade countries have invested billions in preparedness strategies, plans, departments and agencies, and special legislation (preparedness acts) has been adopted. Planning and preparedness are typically done by states (e.g. the Federal Emergency Management Agency in the US) .

The emphasis on preparedness is related to the present-day tendencies to consider catastrophic threats primarily as national security threats and no longer as public health problems whether or not it concerns pandemics, bioterrorism , earthquakes or nuclear proliferation. While the rationality of prevention is linked to public health, within a security perspective on-going vigilance is required. This societal approach to threats is driven by, what Andrew Lakoff (2008) has called ‘vital systems security’. Preparedness , in the politics of security, should not first of all protect the national territory or the population but the critical systems that are essential for social and economic life. This approach to security developed from the practice of civil defence in the 1950s and 1960s. Lakoff shows how the way societies were dealing with the threat of a nuclear catastrophe was gradually extended to approaching natural disasters , technological accidents, terrorist attacks and later disease epidemics. Different stages of global threats can be distinguished. In the 1980s emerging disease threats, particularly emerging viral outbreaks, were the object of concerns. In the 1990s anxiety about bioterrorism (linked to disease agents such as a possible smallpox attack) were dominant. In the 2000s the focus is more on natural disasters and pandemics. It seems that there is an ever widening range of possible threats so that preparedness now has to include ‘all-hazards planning’. The policy implications of such evolving threats are clear. How can we respond at all to such wide ranging catastrophic events? The only imaginable response is a global one. By implication, the only state agencies or departments that have the planning capacity , logistics and resources to conduct relief operations are the Departments of Defence. Non-military agencies like the United Nations or the World Health Organization (WHO) cannot accomplish this task because they don’t have the logistical machinery unless provided by Member States which will take time to coordinate.

The notion of preparedness therefore brings in a specific perspective and a particular logic of action (Lakoff 2007) . Only certain types of problems become visible as targets of intervention . If preparedness efforts are primarily concerned with the vital infrastructure and not with population security then the global living conditions of populations (determined by poverty and lack of basic public health infrastructure) remain outside the scope of preparedness . The only imaginable response is a global one under military supervision.

The question has been raised regarding what bioethics can contribute to this new area of disaster response planning (Berg and King 2006) . Bioethicists have a lot of experience for example with complex decision-making in situations of urgency. They have also actively promoted advance care planning in end-of-life decision-making. These experiences can therefore be used in the new disaster preparedness. But these contributions all focus on micro-ethics . Indeed, an increasing range of ethical problems have been identified at the level of personal interactions between care providers and care recipients. From a macro-ethical perspective on the other hand, critical questions need to be asked about the underlying assumptions in disaster response planning and about the moral implications of notions such as disaster and preparedness.

3 Moral Representations

3.1 The Moral Geography of Disasters

Definitions and classifications of disasters differ. Definitions generally combine several elements but a basic distinction is made between natural and man-made disasters .

The International Federation of the Red Cross and Red Crescent Societies (IFRC) is developing a standardised international classification of disasters. Its World Disaster Report 2010 distinguishes two generic categories for disasters : natural disasters and technological disasters . The natural disasters category is divided into five sub-groups, which in turn cover 12 disaster types and more than 32 sub-types, for example biological disasters (epidemics) and geophysical disasters (earthquakes and tsunamis). The technological disasters category includes, for example, industrial accidents and transport accidents. These two categories of disasters are frequent. Over the last 10 years more than 7,000 disasters have been reported. More than 1.1 million people have died and more than 2.5 million people have been affected. The total estimated damage is enormous: 986 billion US dollars (IFRC 2010). This classification does not include war , conflict-related famines, diseases and epidemics.

Another approach is to speak about ‘humanitarian disasters’ or ‘emergencies’ and divide them into complex emergencies and natural disasters (Middleton 2010) . The first category of disasters is caused by human violence (as in Somalia, Sudan, Palestine, and Congo). These are primarily political events requiring long-term assistance while popular funding will generally be limited. The relief effort will never be sufficient since progress is always endangered by renewed violence. The second category is caused by natural events such as the 2004 tsunami in the Indian Ocean , the 2010 earthquake in Haiti and the 2011 earthquake and tsunami in Japan . These natural disasters evoke widespread public sympathy and generate substantial public funding. The focus of relief efforts is usually on short-term front-line activities: food, water, shelter , and medical attention.

Both classifications identify a separate category of ‘natural disasters’ . These disasters have the following defining characteristics:

they are unexpected, they come as a surprise, a shock;

they cause great damage, loss, suffering and destruction, creating estrangement because people’s ‘homes’ have been destroyed;

there is no issue of human responsibility ; nobody can be blamed for the fact that the disaster has taken place since there is no human causation.

This last characteristic demarcates natural disasters from man-made ones (Clark 2005; Korf 2006) . Humanitarian disasters caused by civil war for example are the result of human evil. There is a different moral responsibility . Identifying a disaster as ‘natural’ therefore introduces a specific moral discourse. Natural disasters create innocent, ‘pure’ victims. They generate a particular responsiveness ; we are moved because fellow human beings are hurt and in need. Disasters nowadays have a global impact and call for our sympathy, solidarity and generosity. We are touched by personal stories of how human beings are assisting each other. The usual pattern of human interaction based on exchange and self-interest is suddenly transformed. Our world is disturbed by images of distant suffering making us aware that we are all in the same human predicament of fragility, exposing the vulnerability of human beings and inciting reciprocity and unconditional help. Natural disasters are therefore a paradigm case for humanitarian aid . They furthermore highlight the essence of ethics. What is the value of ethics if we don’t care about the victims of such unfortunate events?

However, the usual distinction between natural and man-made disasters , and thus the moral geography it is introducing, is questionable. The origins of disasters can be different and some are indeed not influenced by human beings. But what makes an event into a disaster is its impact on human beings. If there would be an earthquake in a completely uninhabited area without any negative effect on humans, it will be a geophysical event but not a disaster. And in the present-day interconnected world it is difficult to see that a large-scale ‘natural’ disaster does not impact on human beings. But if the human impact is what makes an event disastrous, it is at the same time clear that this negative impact is often the result of prior human interventions that have created conditions of vulnerability.

A comparison of three recent earthquakes quickly shows that poorer and less developed countries are disproportionally impacted. In January 2010 Haiti was struck by an earthquake with a magnitude of 7.0. Ultimately 316,000 people were killed and 1.5 million people made homeless. The economic damage to the island was estimated at $14billion (120 per cent of Haiti’s gross domestic product). The following month, February 2010, a more severe earthquake occurred off the coast of Chile (with a magnitude of 8.8) . Approximately 500 persons were killed and 370,000 homes damaged. The economic damage was estimated between $15–30 billion (10–15 per cent of Chile’s GDP). Very recently, in March 2011, Japan was hit by one of the largest earthquakes ever recorded (with a magnitude of 9.0). The exact number of victims is still unknown but will be approximately be 25,000 with 100,000 buildings damaged or destroyed. Regardless of the magnitude of the earthquake the disaster in Haiti was vastly more destructive and deadly. This is generally attributed to the state of development of the country. Haiti is the poorest country in the western hemisphere; 80 % of the population is living under the poverty line. The enormous number of casualties is not only due to the earthquake but to the extremely poor living conditions and the inability of the state or the population to take protective measures or even to organise relief. The example of Haiti is also ironic (Middleton 2010) . The same countries that have been the first to provide humanitarian assistance were also the ones that have created the long-term conditions for the severe impact of the earthquake. Haiti used to be the richest French colony in the New World. When it declared independence as the first black republic in 1804 it had to provide exorbitant indemnities to France for the next 143 years. All the country’s revenues were used to pay the former colonisers. In 1900 around 80 per cent of the national budget was used in payments to the French. In 1947 when the debt was paid off the Haitian economy was ruined, the land deforested, the population living in poverty and no infrastructure developed (Macintyre 2010) . From this perspective, it is not the geophysical phenomenon that caused the disaster in Haiti but the colonial history .

Another example that demonstrates that disasters are always complex, and involve an interplay between natural processes and human activity, is Hurricane Katrina , one of the worst disasters in US history. This 2005 disaster is analysed by Byron Newberry (2010) using a macro-ethical approach. His analysis is contested since it is not evident that there is an ethical problem at all. For many, the hurricane was a natural hazard . If there have been failures in the hurricane protection system, nobody can be blamed for the devastation of New Orleans. That means that there is no problem to be discussed in terms of ethics; it is simply a technical issue. The power of nature has been so overwhelming that there is no question of negligence or irresponsible behaviour of individual engineers. The vocabulary of ethics, pointing to unethical conduct, responsibility , duties, does not apply. That may be true, Newberry agrees, but for the micro-level of interpersonal interactions. He advocates a macro-ethical point of view focusing on the complex socio-technical systems in which responsibilities are located at various levels of public policy, risk assessment and organisational behaviour. Catastrophic events do not occur as the result of unethical decisions of individuals but as the consequence of the confluence of many, seemingly insignificant decisions at various levels. Newberry shows for example how levees and floodwalls were inadequately constructed, based on wrong assumptions about possible risks. Available information that the hurricane protection system was vulnerable was simply left unused (because it endangered the uniformity of the system or was considered to be too costly). The protection system was furthermore built over a long span of time using the original specifications. However, the environment continued to change, so that the system was inadequate when it was completed. Furthermore, this was known to be the case. In spite of this, a false sense of security was created by suggesting that nature was now under human control.

The disastrous impact of the natural hazard (the hurricane) due to the vulnerabilities of human-constructed systems has, like in Haiti, a social and historical background that make quick and easy remedies unlikely. The city of New Orleans’ susceptibility for disaster is the consequence of centuries of development , human engineering and political decision-making. The establishment of the city took place 300 years ago in precarious conditions, starting a long history of defending it from storms and floods. The city cannot be erased and relocated elsewhere. That means that the problem of flood protection can never be solved; it will require a never-ending, even ever-escalating effort. Problems solved somewhere will return more severely elsewhere. Channelling the river for example has allowed the economic development of land behind the levees but has made the system much more vulnerable. What is at stake is the human effort to preserve New Orleans as a major river/seaport. It is known that the Mississippi river delta is changing every 1,000 years. Human intervention is preventing the delta-switching that normally should have happened already.

This contest between human intervention and nature is in fact creating the vulnerability to disasters. The case of New Orleans resembles the case of my native country, the Netherlands. Obviously policy-makers did not want New Orleans to have the same fate as Bruges, the capital of West Flanders. The name Bruges means ‘landing stage’ or ‘port’, indicating that the city initially was a seaport. Around 1050 this access was lost due to gradual silting. But a major storm in 1134 shifting the coast line created a natural channel so that that access was restored in a different way but Bruges was now 10 miles inland. In the Netherlands, there is already a long list of ‘drowned lands’, settlements lost to the floods (see Wikipedia 2011). But the Dutch don’t want the western, most populated half of the country to disappear into the sea. It is an uphill battle. Risks can never be excluded, even with the most perfect engineering technology. So we know, one day, another disaster will occur. But we cannot only blame nature if we continuously try to domesticate it. The interplay of natural processes and human activity implies that there always is the ethical issue of human responsibility.

3.2 The Moral Geography of Humanitarian Relief

A particular publicity campaign for the US navy on American TV has impressed me. You see warships and soldiers amidst devastation due to disasters such as the 2004 tsunami and the 2010 earthquake in Haiti . Once the heroic music reaches a crescendo you can read: ‘America’s Navy. A global force for good’. The military is nowadays one of the major providers of humanitarian assistance. Four weeks after the 2004 tsunami the White House claimed that 16,000 US troops were engaged in relief work, especially in Indonesia. After the Haiti earthquake, the US Southern Command was coordinating relief efforts. The very next day special operations military arrived in the country. One week later the hospital ship USNS Comfort dropped anchor (Etienne et al. 2010) . Soon more than 22,000 military personnel were involved in the relief effort, engaging 23 US navy ships, 57 helicopters and 264 aircraft.

The present-day connection of humanitarian aid and military intervention is surprising since the so-called first phase of modern humanitarianism was initiated by the horrors of war . Henri Dunant founded in 1863 the International Committee of the Red Cross because he had witnessed the suffering of thousands of wounded soldiers who were simply abandoned at the battle of Solferino. The innovation of Dunant was not so much the creation of a system of care for victims but rather that such system was based on the moral principles of impartiality (relief is solely based on need and provided without any distinction as to nationality, race, religious beliefs, social class or political opinions) and neutrality of the care providers, so that they will be protected and respected by all parties. Dunant’s ideas were soon expanded in two directions. One was that the purpose of providing humane treatment to those injured in war was generalised to providing care for all those who were suffering from floods, famines, earthquakes and epidemics and also to refugees . All those in need due to conflict or disaster will receive basic assistance with food, water, shelter and medical care. The initial ideas were expanded into a set of seven fundamental principles of the Red Cross: humanity , impartiality , neutrality, independence , voluntary service , unity and universality (Barnett and Weiss 2008) . Such principles articulate the moral geography of humanitarian aid: it is by definition disinterested and purely philanthropic.

The concept of neutrality has become more and more difficult to uphold. In practice it is often violated as well as exploited for political purposes. But there are also more fundamental reasons why the primordial ethics of humanitarian assistance have been criticised (Middleton 2010) .

The first reason is that international aid is explicitly regarded as an instrument of foreign policy . In 1918 US President Woodrow Wilson announced his Fourteen Points leading to a new world order with humanitarian assistance as a necessary part of foreign policy. Wilson’s military occupation of Haiti, Santo Domingo, Cuba and Nicaragua were all presented as humanitarian assistance. In 1949, during the emergence of many new states, President Harry Truman launched the phenomenon of foreign aid or development assistance. The justification was moral (Hattori 2003) . More developed states have an obligation to help less developed states. This will contribute to world peace and prosperity. But it also embodies the ideal of humanitarianism . If countries have basic needs and more developed countries are able to satisfy these needs, they should provide relief.

But such assistance is not disinterested. Humanitarian assistance is mostly managed by the ministries of defence and foreign affairs. Ultimately it is not idealism but self-interest of the state that prevails. In 1919 Haiti had been occupied by the US because it was heavily in debt. A system of mass forced labour was set up to make sure that the debt could be paid. The 2004 tsunami relief in Indonesia was followed by enormous arms sales a few weeks later. Foreign aid therefore has been criticised as institutionalising virtuous practices in the interests of the powerful (Hattori 2003) . Its purpose is to legitimise an existing material order through transforming a material hierarchy (global injustice and social inequality) into a moral hierarchy between donor and recipient. The developed and often former colonial states have the virtue of giving, philanthropy and beneficence . Rather than emphasising the rights of recipients, humanitarian aid in this perspective only legitimises the power differences and inequalities that exist.

Secondly, the moral geography of humanitarian aid changed significantly in the 1990s after the end of the Cold War (Smith 2009) . Before that time military interventions were not justified with humanitarian arguments but by the 1990s this had become a legitimate justification. Since then the number of humanitarian operations grew greatly, particularly in response to man-made catastrophes. This is due to a significant increase in the number of interstate conflicts but also to the growing influence of the idea of human rights . In fact humanitarian aid is changing into humanitarian intervention (Chatterdjee and Scheid 2003) . For a long time, the military has assisted in the delivery of humanitarian aid. But since the 1990s military interventions themselves are increasingly justified as ‘humanitarian’. The major motivation for intervention is a moral one. The intervention is ‘humanitarian’ since it is not carried out for the usual military reasons but out of concern to help. Governments themselves fail to protect their citizens or are violating the human rights of their citizens. Military assistance by others is therefore necessary to protect this population even if it means that national sovereignty must be overruled. The crucial notion used in justifications is ‘rescue’: the intervention is necessary in order to rescue and protect the people in a foreign territory from gross violations of their basic human rights (Walzer 1995) . The purpose is saving people from harm done by the same authorities who should protect them. British Prime Minister Blair justified (in 1999) the bombing campaign in Serbia and Kosovo: we are fighting not for territory but for values.

The implication is that the distinction between humanitarian aid and humanitarian intervention is disappearing. Of course military and humanitarian action is not the same. Bombing Kosovo is not equivalent to providing food and shelter to Kosovar refugees . But both are becoming more and more interdependent. Military interventions are legitimised by calling on humanitarian organisations; these organisations need the military to guarantee their safety. More importantly, both have the same aim: rescuing the innocent and helpless. Both are guided by the same sentiments of compassion and humanity . Both appeal to a higher moral order (Wheeler 1997) . Conflicts and disasters are now included in the same logic of humanitarian relief (Fassin and Pandolfi 2010) . This contemporary logic reflects an important change in international thinking due to processes of globalisation . The principle of non-intervention that used to regulate the relations between nations was based on the value of national sovereignty and on the position that states only act when it is in their own interest and not for moral reasons. This respect for state sovereignty is now superseded by the global norms of human rights and human dignity . National sovereignty has a subsidiary value. It is therefore conditional: states only have immunity from foreign intervention as long as they treat their citizens decently. In other words, the political order is now subordinated in a global moral order. States are subject to a higher normative order. The underlying conception is that of global moral community or shared humanity (Nardin 2009) . The same process is at work in the expansion of bioethics into global bioethics. The notion of moral community is extended to the global level. At this level universal principles are at work, which request us to prevent or mitigate evil when we have the capacity to do so. The ultimate sovereign of the global community is humanity, one of the defining principles of humanitarian action (Charvet 1997) . The moral imperative to assist and intervene is expressed in a new language of humanitarianism , emphasising cosmopolitanism, common humanity and the responsibility to protect (R2P) and focusing on the victim’s point of view (Benhabib 2009) .

3.3 Emergency Ethics

The war in Biafra (1967–1970) was the origin of the so-called second phase of modern humanitarianism . Because the Nigerian government did not allow any relief into the area where it was most needed, some Red Cross doctors departed from the principle of neutrality and spoke out for the victims. This led to the establishment of the new relief organisation Médecins sans Frontières (MSF) in 1971. The Red Cross has been criticised for its consistent stance of impartiality and neutrality, for example, when it visited the Nazi concentration camps during World War II but did not report on what was going on there, or more recently when Red Cross workers paid visits to Guantanamo Bay only on condition that they did not report (Brauman 2009) . The basic idea of MSF is that in some circumstances it might be in the interest of the victims not to maintain silence but to speak out. One cannot close one’s eyes to violations of human rights , especially when the parties that are committing those violations are also in control of the relief efforts. Not taking sides and remaining silent is no longer in the interests of the victims; in such conditions one has to testify about the injustices and violations. Intervention may be mandated, in the words of Bernard Kouchner, by an ‘emergency ethics’ (‘une morale de l’extrême urgence’; Perrot 2006) .

The foundation of MSF symbolises the change from aid to action. It represents an ethics in action, promoting humanitarianism as a new repertoire for public action (Fassin 2007) . For many people today, humanitarianism is synonymous with ‘doing good’; it is the symbol of selfless action; it represents the ideal of a better, more humane world (Barnett and Weiss 2008) . The prototype of the humanitarian worker is the Good Samaritan . The moral reasoning behind humanitarian action is obvious: protect populations, save lives, relieve suffering.

However, the humanitarian discourse cannot be taken for granted. It incorporates and expresses particular values that are taken as self-evident but often these values are given priority over other possible values. It is also assumed that emergencies, exceptions and the need to intervene are self-evident, as if we would not have other choices from an ethical perspective. In this regard it is interesting to study the work of the French physician and anthropologist Didier Fassin who has analysed the humanitarian discourse (Fassin 2007, 2008, 2010) .

The fundamental value of this discourse is human life. The basic justification of humanitarian action is saving life. This is the first-order principle, while neutrality, impartiality or consent are second-order principles. This principle inspires the world view of many nongovernmental organisations (NGOs) : they come in to assist vulnerable populations, to help victims of natural or man-made disasters . They have no political agenda or power claims. Their only power consists in the powerless. In distinction to politics which sacrifices, humanitarianism saves and rescues. In the fight between good and evil, they are on the right side.

Humanitarianism is also a powerful discourse since it combines the rational and the emotional. Humanitarian reason is inspiring solidarity, and humanitarian sentiment motivates compassion . These two dimensions are embedded in the notion ‘humanitas’ (the French term ‘humanité’ has the same double meaning): humanity as an ethical category including all human beings (‘humankind’, ‘Menschheit’) is the basis for solidarity; and humanity as concern for other human beings (‘humaneness’; ‘Menschlichkeit’) is the basis for compassion, even with distant suffering . The bringing together of solidarity and compassion implies that there should not be distinctions among human beings (humanity is one and indivisible) nor should there be indifference to distant others. Distance and distinction are simultaneously transcended in the same discourse.

Fassin shows that in humanitarian practice things are more complicated. Human lives are not equal. There is always a balance between lives to be saved and lives to be risked. When a Stanford emergency team arrived in Haiti 5 days after the earthquake in 2010, they provided care to hundreds of people in the university hospital. But at the end of the day the medical team was leaving the hospital (because of security reasons) knowing that nobody was available to manage the pain and take care of patients during the night (Camacho-McAdoo 2010) . Humanitarian missions can be dangerous. Although biologically, lives are the same, philosophically they are different. Humanitarian workers can choose to sacrifice themselves for a good cause. Victims have no choice, they are sacrificed (in the language of Fassin). Because lives are sacred , humanitarianism can demand the potential sacrifice of one’s life. But there is a difference between ‘bare life’ to be assisted and the political life that is freely risked, or between the zoe of populations harmed by disasters and the bios of citizens of the world who come to their rescue (Agamben 1998) . Not all lives have the same value. Fassin (2007) demonstrates this with the example of policies in case aid workers are kidnapped or abducted, and with the difference made in MSF missions between expatriate and national staff. The same inequality pertains in humanitarian interventions . For the sacred life of the intervening ‘humanitarian’ soldier, it is deemed worth sacrificing the life of hundreds or thousands of people (soldiers or not) on the other side.

Humanitarianism therefore should be defined as “politics of life” (Fassin 2007) . It is different from the ‘biopolitics’ espoused by Michel Foucault since it is not concerned about populations but rather with the lives of individuals. At the same time it is politics since it implies selecting which lives are possibly or legitimately to be saved. For example, humanitarian workers have to consider which AIDS patients should receive antiretroviral medications, or whether assistance should be provided to persons who have participated in massacres.

The radical inequality of lives is furthermore demonstrated in the creation of victimhood (Fassin and Rechtman 2009) . The articulation of reason and emotion in humanitarianism is generating a specific attitude towards other human beings. The other is regarded as vulnerable and traumatised. He or she no longer is a survivor or hero but a victim (Debrix 1998) . In his studies of the Palestinian Territories, Fassin shows how humanitarianism translates political domination and violence into suffering and trauma. The focus on human life transforms people who are resisting or protesting into victims. Humanitarianism requires protecting and caring for all victims; there are neither good nor bad victims. But one can never help all victims. Tragic choices need to be made.

Contemporary humanitarianism as ethics in action is not only providing care but also bearing witness . It is speaking out on behalf of the victims. Such humanitarian testimony introduces a distinction between those who are subject (the witnesses who testify, usually the humanitarian workers) and those who are object (the victims whose suffering is testified). Those who show compassion take on the role of witness for those they assist. Testimony in this way reiterates two forms of humanity : those who can tell stories and those whose stories can only be told by others. Again ‘bare life’ is transformed into qualified ‘political life’. Through the humanitarian testimony mere physical survival will become social existence that is more powerful in eliciting compassion and the need for assistance. But the transforming act is done by a third person, the transforming subject, i.e. the humanitarian worker. At the same time the object of transformation is reduced to victim. The young Palestinian stone thrower is no longer a hero but has become fragile, vulnerable, traumatised. The logic of compassion is replacing the demand for justice (Fassin 2008) .

4 Different Perspectives

Humanitarianism as politics of life is nowadays the most powerful language for public action. It is re-establishing solidarity among human beings and it gives equal value to all lives. Humanitarianism is furthermore the best contemporary expression of a cosmopolitan ethics in which international borders, cultural diversities and political ideologies are irrelevant in the face of human suffering . But in practice it is problematic since it not merely highlights the value of human life but is also associated with, in the words of Fassin, a ‘complex ontology of inequality’ (Fassin 2007, p. 219) . It makes distinctions between lives that may be risked and lives that can be sacrificed, between lives that have higher value and those that have limited protection, and between lives that are narrated in the first person and lives that are only recounted in the third person. Finally it is problematic as politics since it is introducing morality into the political sphere. Fassin does not hesitate to speak of a new type of governance, viz. ‘humanitarian government’ (Fassin and Pandolfi 2010) . Now that political ideology has retreated since the end of the Cold War , the space is filled by humanitarianism which is now the apogee of the ideal of human solidarity. The new discourse demands that we assist, even if necessary intervene, because it is a moral obligation rather than a legal or political principle. The politics of assistance and intervention are now justified in the name of humanitarian morality. Protection of peoples and saving lives is more important than respect for the sovereignty of states. Morality justifies the suspension of the rule of law. The ethics of emergency presupposes that we live in a state of exception established at global level. There are perennial emergencies. Nothing is normal. The continuous state of exception is justified by the urgency of situations (emergencies) as well as the danger to the victims (rescue, protection, security ).

The same logic of intervention can therefore be applied in assisting the victims of civil war in Somalia as in aiding the victims of the tsunami in Sri Lanka . The paradigm of disaster prevails over the paradigm of war . In this logic there is no essential difference between disasters and conflicts. The world’s disorders, whether natural or human in origin, become humanised. Natural disasters become humanised—not simply the result of brute force of nature; while violence and conflict become naturalised—not merely the result of brute human force. By equating the two types of emergencies, the only issue is aid to the victims; the local context with its history and socio-economic tensions is less relevant. Human conflicts become depoliticised: the historical background and the conflict setting are displaced by urgency and compassion . But it also means that macro-ethical questions regarding disasters are no longer relevant.

4.1 The Value of Life and Justice

At the same time, solidarity and compassion are not unlimited. Humanitarian efforts cannot relieve all suffering everywhere. And interventions to bring about a world in which violations of human dignity do not take place are a drop in the ocean. Often humanitarianism is selective (Brown 2003) . We intervene in Libya but not in Yemen, Bahrain or Syria. There are also huge gaps in aid spending: $33.9 million per death from Hurricane Katrina in 2005, $35,336 per death from the 2004 tsunami, $2,483 per death in the 2005 Pakistan earthquake , and $1,968 per HIV/AIDS death in 2004 (Wolinsky 2007) . Similar differences exist in famine aid. Substantially more food aid was generated for Kosovar refugees in 1998 than for Liberian refugees in the same period of time (Rinehart 2002) . If all human lives are of equal value, why is there unequal treatment?

Elaborating on the differences in responses to large-scale human tragedies like the 2004 tsunami and the HIV/AIDS pandemic , Christie et al. (2007) suggest that it might be the apparent morally neutral nature of the tsunami disaster that was responsible for the massive resource mobilisation. Nobody is to blame for a natural disaster , and the victims are clearly innocent, while HIV/AIDS is spread via human conduct. This different response illustrates once again the inequality of human life that is associated with humanitarianism. It also illustrates the powerful rhetoric of disasters as natural events that can drive public generosity and the philanthropic enterprise. The international response to the catastrophe is ethically praiseworthy but should at the same time be ethically criticised since it is unjust. There is no morally relevant difference between the two tragedies justifying the difference in response. The discrepancy makes clear that human life is not the only relevant value at stake; justice is another.

4.2 Triaging Humanitarian Interventions

The critique of selective humanitarianism has instigated reflection on the moral criteria for choosing where and when to relieve suffering. Brown (2003) for example has suggested simple triage rules for deciding what sorts of interventions should be undertaken. He distinguishes three categories of situations in the world: (1) difficulties that are sufficiently minor that intervention would do more harm than good, (2) difficulties that are of such magnitude that action would be ineffective (e.g. the devastation is simply too extensive, like in the Democratic Republic of Congo) or would be counterproductive (e.g. in Tibet or Chechnya where a powerful government can make intervention into a more widespread disaster), and (3) situations where intervention is practically possible and has the prospect of bringing improvements. In developing selection criteria many political philosophers in fact are taking older criteria from the Just War tradition (just cause; right intention; proper authority; proportionality; last resort; prospect of success; care being taken to protect the innocent) and applying them to the circumstances of humanitarian intervention (Coady 2003) .

4.3 Allocation Decisions in Aid

How are resource allocation decisions made in humanitarian aid? Some commentators are pessimistic and accept that there is no rational coordination, no commonly shared targets, and no clear rationale; there is just ‘chaotic do-gooder-ism’ (Wolinsky 2007) . Often decision-making is not transparent. Most NGOs are self-mandating and self-regulating; they have full discretionary power over what they do. Fuller (2006) examined the justifications given for resource allocation decisions at Headquarters level in MSF and identified three types:

  1. 1.

    Public health perspective . Decisions are based on population statistics (e.g., the outbreak of specific diseases). As soon as the outbreak is controlled, it is useful to close a project; the disaster is over. This type of decision-making is most appropriate in an acute crisis focused on a particular problem. The most urgent need has priority.

  2. 2.

    Organisational perspective. Decisions are based on the mandate or mission of the organisation. For MSF for example, there should be a crisis with humanitarian and medical components.

  3. 3.

    Community perspective. Decisions are based on advocacy arguments. Relationships already exist between certain populations, and these relationships generate special responsibilities. The projects are also setting an example; they show that certain treatments will work in certain circumstances.

Instead of identifying a set of clear criteria, Fuller’s study reveals competing moral views. Those views are focused on the one hand on severity of need and the likelihood of securing good outcomes or on the urgency of the situation. On the other hand they are focused on the existing relationships of trust, cooperation, vulnerability and dependence. All views presuppose the basic value of saving human lives but differences appear in connection with the means to accomplish the goals of rescue and protection. It is clear that a comprehensive framework of selection criteria is lacking, although some elements reminiscent of the Just War theory are there, such as considerations of cause, means and ends (Ford et al. 2010) .

4.4 Human Life and Human Rights

Even if today’s humanitarianism is considered as emergency ethics , many humanitarian efforts are in fact struggling with more values than simply saving human lives (Slim 1997) . The value of life continuously competes with values like human dignity and justice . As mentioned earlier, the focus on human life transforms people into victims. This will position them as traumatised persons in need, putting the social and political context between brackets. Humanitarianism as politics of life will also continuously evoke our sentiments of compassion . By calling for philanthropy , generosity and charity it will never basically challenge the politics that permit war, famine and suffering. The ethical drive embedded in humanitarianism is so strong and compelling that it can hardly be criticised; at the same time, it directs our focus on immediate relief for individual victims so that we tend to forget that other dimensions are equally important. One dimension, mentioned above, is the social context which is often unjust. Another dimension is the perspective of the recipient. In many humanitarian operations the persons who receive assistance are absent and silent (Barnett and Weiss 2008) . The failure to give voice to the vulnerable is remarkable since the ethics of humanitarianism is based on the notion of human dignity .

It is therefore argued that humanitarianism should be redefined in terms of rights (Slim 2002) . Instead of the language of needs and compassion we should use the language of human rights and dignity. Within the recent discourses of the United Nations, the Red Cross and NGOs , more emphasis is needed nowadays on rights-based humanitarianism. Poverty and development have been redefined in terms of human rights .

The advantage of this approach is that humanitarianism will be grounded on an integrated moral-legal framework of international human rights law. It will be more than just a moral endeavour but will also be anchored in institutions (courts, tribunals, truth commissions), even if they are not recognised by all states.

The second advantage is that rights dignify rather than victimise. People are no longer regarded as needy victims but as citizens of the world with the same claims and rights as everyone else. Human rights make people equal and more powerful. They provide a universal and objective standard to assess human behaviour (Slim 2002) . This does not ignore the many problems in the global application of this approach. But the fact is that all states have and still are participating in the norm-creating process in which these international standards are articulated.

The third advantage of the human rights approach is that it generates foreign policy imperatives as expressions of international responsibility . Membership of the international community entails recognition of the moral urgency of human rights . Kelly (2004) has identified three such moral obligations: non-engagement, aid, and intervention. The modalities of humanitarianism are, in his view, guided by the shared concern for human rights.

5 Conclusion

Analysing disaster planning and humanitarian aid from a macro-ethical perspective produces a paradoxical conclusion: macro-issues concerning context and background are irrelevant in the prevailing logic of disaster relief. What ethically matters in today’s humanitarianism is saving lives, rescuing individuals and protecting populations.

The dominant ethical framework of disaster relief has two consequences. First, the focus on emergency ethics makes it difficult to provide structural, long-term aid. Global intervention and assistance are driven by compassion with fellow human beings in situations of crisis. But why does this recognition of our common humanity not lead us to consider deeper causes of suffering in the social and economic context? We feel compelled to act as moral agents out of solidarity with the global community but then we only address crises and emergencies, not the human wrongs of poverty and starvation. It seems that we don’t spare efforts to save the lives of victims of sudden natural disasters but accept the slow death through poverty and malnutrition . The public health system around the globe has more or less collapsed (Garrett 2007) . Poor living conditions in many countries are the source of global disease threats. Even the efficiency of humanitarian aid is rather low if poor hygiene and sanitary conditions will not be improved. While each day more than 10,000 children die from diarrhoea, suffering only seems to generate compassion and humanitarian relief if it is caused by natural disasters . This focus of humanitarian assistance can easily be regarded as an alibi for not changing lifestyle and consumption patterns in countries providing such assistance (Wheeler 1997) . Despite all the compassion, charity and solidarity, global suffering continues. We have not learned the lessons from an earlier decade when bioterrorism was presented as a major threat to health and security . Since the 1990s tens of billions have been spent on ‘biodefense’ (King 2005) . Preparedness programs have created the impression of immediate action. But in fact resources have been spent for hypothetical threats and were diverted away from more pressing public health needs.

The second consequence of humanitarian emergency ethics is that the voice of the recipient of assistance is absent. Again an analogy can be made with the approach of homeland security in the United States. A massive security apparatus and bureaucracy has been established that enforces top-down security measures. Civil society and citizens are not engaged. Individual resilience is not promoted so that in fact individuals have become increasingly complacent and helpless in the face of threats and disasters (Flynn 2011) . In the perspective of humanitarian aid , the distant others who are harmed by disasters are helpless and vulnerable; they deserve compassion and assistance. In reality, most survivors of disasters owe their lives to neighbours and local authorities. It is a myth that they are waiting to be saved by international rescue teams (De Ville de Goyet 2000) . Nonetheless, the relationship between provider and recipient of assistance is often asymmetrical. The recipients are not the ones that determine their own needs. They are not visible as moral agents but as devastated, silent victims. With the best intentions aid is provided but often with a reduced view of the person as only being in need of basic issues such as food, water, shelter and medical care. Recipients are not supposed to participate in determining their own destiny. Brauman (2009) illustrates how this may lead to misdirected aid. During the war in Mogadishu for example the only way to save the life of some persons was by amputation . But many wounded young people refused to be amputated since they did want to live with a visible mutilation. During the recent Haiti earthquake several thousand people were amputated without consideration of their long-term quality of life in one of the poorest nations in the world. What is beneficial for the disaster victim can only be determined through focusing on the larger context of human reality beyond the immediate emergency situation. Within the perspective of emergency ethics what counts is saving the life of the victim but what is forgotten is life before and after victimhood .