Life in Crisis: The Ethical Journey of Doctors Without Borders – reviewed by Dr Jacob Fanus Dreyer

‘Life in Crisis: The Ethical Journey of Doctors Without Borders’ by Peter Redfield (University of California Press, 2013). 

life in crisisThis book is an ethnographic report on the conceptual, intellectual and practical journey of the ethical principles and practice of the founding, development and maturation of Medicins Sans Frontieres (MSF)in its role as a major global activist in humanitarian medicine. Peter Redfield has spent almost 10 years either embedded with MSF missions or interviewing field and office staff of various missions. He describes MSF’s progression from ‘oppositional idealism’ (p.3) to humanitarianism operating ‘in a coalition’ (see p.246). This book examines the zeitgeist, humanitarian crises and ethical principle of the ‘sanctity of life’ that led to the formation of MSF and the organisation having a strong stance on the ethics of‘temoignage’ (witnessing or advocacy) (see pp 99-105). Redfield then charts the subtle changes in MSF’s raison d’être over four decades, evolving from its focus on medical emergencies to providing longer term humanitarian services with ‘an ever-cantankerous edge’ (p.243) in order to fulfil its perceived role in global humanitarian health.

The story is told as in a bildungsroman, with MSF defining their humanitarian agenda through strong secular belief in human virtue and common decency (p.2), and is enriched with multiple ethnographic anecdotes and case studies to give the narrative a human face. The focus remains on ethical dilemmas that shaped MSF’s collective thinking, which has always consisted of strong individual opinions, often in conflict, openly challenging both itself and the establishment. It becomes clear that ‘sans Frontieres’ is a reference to the organisation’s charter to cross both national borders anywhere in the world as well as conceptual boundaries of what humanitarianism should entail.Redfield illustrates this with notable examples, such as MSF’s criticism ofthe Ethiopian government during the ‘Live Aid’ famine (p.62), recommending an intervention to stop the Rwandan genocide (p.64), and also opposing the concept of ‘humanitarian wars’ (p.163).

The book consists of three parts, entitled ‘Terms of Engagement’, ‘Global Ambitions’and ‘Testing Limits’. Redfield first guides the reader through the development of humanitarian aid, from the Red Cross to the founding of MSF. This is followed by a discussion of the parallels that led to the two organisations to be awarded the Nobel Peace Prize 99 years apart, but more importantly how they fundamentally differ in philosophy and practice.  MSF is founded on a strong secular belief in the value of life, based on the philosophy of secular enlightenment of Voltaire (p.42), which means that every life is considered equally sacred, and that no life can ever justifiably be sacrificed for another or for a higher good (p.42). MSF do not, however, try to define a philosophy of life, but simply argue that ‘life is simply to be saved’ (p.65). Simply put, saving a life does not mean denying death, but that ‘people shouldn’t die of stupid things’ (p.65).

Part two explores the essential principles of MSF’s field work in a series of appropriately named chapters, ‘Vital Mobility’, ‘Moral Witness’ and ‘Human Frontiers’. In ‘Vital Mobility’, Redfield discusses the practicality and ethos of MSF’s ‘kit culture’ which allows personnel to rapidly respond to any emergency within 48 hours. There is a ‘kit’ for cholera, Ebola and anything else that MSF had ever dealt with, described as an ‘open container for a closed world’ (p.90). Even the medical staff could be regarded as being available in kit form, packaged according to need as ‘an emergency room team, on call worldwide’ (p.13). The chapter ‘Moral Witness’ unravels  the ethical conflict of witnessing disaster (in all senses of the word) when in the field, and how MSF’s responses differed according to the situation at hand. This was initially through speaking out about injustices witnessed (temoignage, best translated as advocacy) and later through its own epidemiological research and both scientific and lay publications. Since their inception, MSF have practiced an ‘ethic of refusal’, meaning simply to not accept the world as it is (p.101).  MSF has always upheld the view that while ‘words might not always save lives, “silence can certainly kill”’ (p.99). ‘Human Frontiers’ discusses the practicalities of crossing borders, coping with political authority, as well as the potential – and reality – of tension between the two groups of people that work for MSF: foreigners (‘expats’) and ‘national staff’. This is illustrated by a series of reflections from MSF personnel, elucidating the ethical complexities of volunteering versus employment.

Part three discusses the realities of MSF’s work through four chapters. ‘The Problem of Triage’ discusses how the concept of clinical triage in emergencies has been adopted to decide where best to allocate MSF’s limited resources, and the philosophical and ethical issues around such decision making. It follows how ethical decision making was applied to humanitarian emergencies (not permitting ‘meaningless suffering’ or ‘stupid deaths’) and in opposition to ‘just wars’. This was due to the unnecessary suffering the latter bring (p.166), which ultimately guided MSF to an evolved realisation that ‘life is about living, not only survival’ (p.177). “The Longue Duree of Disease” looks at crises beyond emergencies that MSF had responded to, such as sleeping sickness, HIV/AIDS and access to essential medicines, and the changes in humanitarian philosophy and ethos that came with commitment to these crises. Ironically it is the access to anti-retroviral drugs to AIDS patients that led to rejuvenated activism and engagement within MSF, delivering some success stories (p.246). In “The Verge of Crisis” Redfield looks specifically at MSF’s role in Uganda where they did not get involved because of natural disaster or major conflict, but where humanitarian need has been on the verge of crisis for decades.  While sharply defined emergencies bring moral clarity, it is more difficult to judge where and how to deliver humanitarian medicine when a community exists not in, but on the verge of, a crisis (p.227). It becomes even harder to know when to cease humanitarian support because, ‘rather than one drowning victim an indistinct crowd struggles in the surf’ (p.228). The last chapter, ‘Action beyond Optimism’, looks at the outcomes of MSF’s humanitarian work. Emergency medicine relief delivers no clear solutions and no final answers; MSF cannot measure long-term success. When they expanded into non-emergency work they encountered a ‘broader wasteland of human need’ (p.230) and seldomly produced sustainable results. MSF do not attempt to promote social justice beyond medical issues or suggest that they can change the world. Their nomadic character defines their collective and individual ethos of action. MSF do not practice humanitarian medicine because they are optimistic about a better world; they are only concerned with the secular sanctity of life, meaning that no one should die a needless death. As Redfield notes, ‘simply put, MSF have no plan’ (p.236) for the future of humanity; it does its work without optimism, looking at ‘a resolutely bleak horizon’(p.241). Maybe the collective mindset can be best described as ‘hyperactive pessimism’ (p.241), a drive to act wherever and whenever emergencies and slow moving crises are threatening human life.

Ultimately Redfield concurs with MSF’s own acknowledgement that they cannot save the world, and cannot alone overcome the ‘the inefficiency of poverty’. Instead, they partake in ‘the greater humanitarian illusion that “something is being done”’ (p241) by practicing ‘rebellious humanitarianism’ (p.98) and standing for virtue in a post-utopian age through the ‘ethics of refusal’.

This not an easy book to read. The reader needs some background knowledge of humanitarian work and/or areas of conflict and disaster. For scholars in the field it is invaluable, however, when approached as an academic resource. Redfield has researched his topic well, thought deeply about ethics and its implications, and makes his points logically and convincingly.

Reviewed by Dr Jacob (Fanus) Dreyer, a consultant general surgeon at NHS Dumfries & Galloway who originally trained at Stellenbosch University and Tygerberg Hospital (South Africa). He has special interests in surgical professionalism, non-technical skills, surgical humanities, critical care teaching, surgical education in sub-Saharan Africa, and global surgery. He is a member of the Global Health Academy of the University of Edinburgh, chairs the International Development Committee of the Association of Surgeons of Great Britain and Ireland (ASGBI) and is a member of ASGBI’s Scientific Committee. He regularly teaches in East and Central Africa, mainly in critical care and Safe Surgery, is editor of a critical care series of open access articles for Africa published through the University of Toronto and has published a handbook for critical care teaching in Africa.

Correspondence to Dr Jacob Fanus Dreyer

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