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In: Voices in Bioethics, Columbia University Libraries, Vol. 7 ( 2021-09-27)

Kurzfassung: Photo by Sébastien Goldberg on Unsplash ABSTRACT Rohingya women face challenges that ought to be acknowledged and addressed to ensure that when they seek health care, they can act autonomously and decide freely among available options. Self-determination theory offers valuable insight into supporting these women within their unique situations. INTRODUCTION In August of 2017, military and paramilitary forces in Myanmar began purging the Rohingya Muslim population from the country, motivated by anti-Muslim prejudice of the Buddhist political and social majority. Mass murder, property destruction, kidnapping, torture, and sexual violence still affect Rohingya communities. As a result, more than a million individuals have fled Myanmar.[1] As of February 2021, approximately 880,000 Rohingya Muslims have taken refuge in Cox’s Bazar, Bangladesh, the site of the largest refugee camps in the world.[2] The public health focus in these camps is on treatment of physical ailments and infectious diseases.[3] While women of reproductive age and adolescent girls experience the highest level of violence among Rohingya communities in both Myanmar and Bangladesh, they have consistently lacked access to sufficient sexual and reproductive care. In 1994, the Women’s Commission for Refugee Women and Children exposed issues surrounding the sexual and reproductive health of displaced populations and propelled the recognition of SRH as a human right.[4] Human rights interventionists and public health officials have made progress in the integration of sexual and reproductive health education, facilities, and resources into refugee camps in Cox’s Bazar. This includes the introduction of menstrual cleanliness facilities and educational conversations. However, Rohingya women and male cultural leaders, or gatekeepers, remain reluctant to accept these resources and education.[5] The prevalence of gender-based violence against women and restrictive policies enforced by the Bangladesh government heighten the barriers to the effective introduction of sexual and reproductive health resources and services.[6]  A wealth of literature has pushed for the extension of clinical duties of beneficence and non-maleficence in the diagnosis and treatment of refugee and asylum-seeking communities.[7] Additionally, extensive research on Rohingya refugee communities has searched for ways to work around the complex social history and to accommodate power structures by integrating gatekeepers into SRH discussions.[8] However, as interventions have sought to overcome cultural and religious barriers, they have largely overlooked the protection of autonomy of sexual and reproductive health patients in Cox’s Bazar. This paper argues two points. First, attempts at improving outcomes in Cox’s Bazar ought to lead to Rohingya women’s autonomy and self-determination, both in mitigating control of male leaders over sexual and reproductive decisions and in ensuring the understanding and informed consent between patients and providers. Second, policy decisions ought to ensure post-treatment comprehensive care to shield Rohingya women from retribution by male community members. Self-determination theory offers guidance for state leaders and healthcare providers in pursuing these goals. l.     Barriers to Sexual and Reproductive Health Services for Rohingya Women As part of its anti-Muslim narrative, the Buddhist majority has painted Rohingya women as hyper-reproductive. False narratives “of a Rohingya plan to spread Islam by driving demographic shifts” and accusations against Rohingya women for having “unusually large families” have motivated violent behavior and discriminatory regulations against Rohingya communities.[9] In reality, demographic data shows that “the Rohingya population has remained stable at 4% since 1980.”[10] In 2013, the government of Myanmar imposed regulations on Rohingya families in the Rakhine state, the region with the highest population of Rohingya Muslims, enforcing a two-child limit and requiring that Rohingya women obtain government authorization to marry and take a pregnancy test before receiving such permis sion. The majority has also subjected Rohingya females to acts of sexual violence to ostracize them and “dilute” Rohingya identity.[11] As a result, Rohingya women in Cox’s Bazar experience unique illnesses and vulnerabilities requiring imminent treatment. Due to national policies in Bangladesh, “Rohingya [women] cannot receive HIV/AIDS testing and treatment in camps; birth control implants delivered by midwives; and comprehensive abortion care.”[12] Additionally, in accordance with patriarchal Rohingya community structure, male gatekeepers hold high authority over sexual and reproductive decisions of women, evidenced by the persistence of gender-based violence within refugee camps and traditional practices such as the marriage of minor girls to older Rohingya men.[13] Surveys of community members reveal that cultural and religious stigma against sexual and reproductive health care exists among these male gatekeepers as well as Rohingya women.[14] Due to their cultural and political position, Rohingya women are subject to unique power relations. This paper analyzes the ethical dilemmas that arise from two of those power relations: Rohingya women’s relationships with male gatekeepers and their relationships with interventionist healthcare providers. ll.     Ethics of Including Male Community Members in Decisions Affecting Women’s Healthcare Autonomy A November 2019 survey of Rohingya women in Cox’s Bazar that had married or given birth within the past two years found that “around one half of the female Rohingya refugees do not use contraceptives, mainly because of their husbands’ disapproval and their religious beliefs.”[15] There are widespread misconceptions such as the belief that Islam does not permit the use of contraceptives.[16] The existence of such misconceptions and the power husbands and male leaders hold over the delivery of treatment creates dilemmas for healthcare practitioners in conforming to ethical principles of care. lll.     Beneficence in Providing Care to Refugees While public health scholars and government officials hold divided opinions on the level of treatment required to fulfill refugees’ right to sexual and reproductive health care, most support enough care to ensure physical and psychological well-being.[17] Beneficence requires that healthcare providers and states “protect the rights of others[,] prevent harm from occurring to others[, and] remove conditions that will cause harm to others.”[18] Under the principle of beneficence, there is a duty to provide sexual and reproductive treatment to Rohingya women in Cox’s Bazar that is comparable to that received by citizens of the host state. In addition, the ethical principle of nonmaleficence may call for the creation of specialized care facilities for refugee communities, because a lack of response to refugees’ vulnerability and psychological trauma has the potential to generate additional harm.[19] In response to gendered power relations among the Rohingya community, husbands and male leaders are included in decisions surrounding maternal health and sexual and reproductive care for women. For example, healthcare professionals “have been found to impose conditions on SRH [sexual reproductive health] care that are not stated in the national… [menstrual regulation] guidelines, such as having a husband’s permission.”[20] The refugee healthcare community could do more to mitigate the potential of retribution taken by male community members against women that accept care by dispelling common misconceptions and precluding male community members from influencing female reproductive choices.[21] However, some current practices allow the infiltration of male community leaders and husbands into the diagnosis, decision-making, and treatment spaces. Deferring decisions to male leaders for the sake of expediency risks conditioning women’s access to care on male buy-in and diminishes Rohingya women’s autonomy over their sexual and reproductive health. lV.     Male Influence and Female Autonomy Ensuring patients control their own treatment decisions is an essential component of the ethical obligation of healthcare professionals to respect patients’ autonomy. While patients can exercise their autonomy to accept the direction of the community, their autonomy is undermined when “external sources or internal states… rob [such persons]… of self-directedness.”[22] Sexual and reproductive health research on Rohingya women revealed that the presence of male family members during conversations “made female respondents uncomfortable to speak openly about their SRH [sexual and reproductive health]related experiences.”[23] The same study found that when male family members were absent, Rohingya women were more transparent and willing to discuss such topics.[24] These findings indicate that the mere presence of male family members exerts control over Rohingya women in conversations with practitioners. Male involvement also stalls conversations between providers and Rohingya women which may harm the achievement of understanding and informed consent in diagnosis and treatment spaces.[25] Women do have the option of bringing their male community leaders and family members into sexual health discussions. Yet healthcare providers ought to monitor patients individually and avoid programmatic decision making regarding male involvement in the treatment space. While it is the ethical imperative of health interventionists and the state of Bangladesh to fulfill the duties of care required by the principles of beneficence and non-maleficence, the sole prioritization of expanding sexual and reproductive health care in Cox’s Bazar risks ignoring autonomy. V.     Ethics of Paternalism in Provide-Patient Relations Rohingya women’s negative beliefs about contraceptives, such as the belief that they cause irreversible sterilization, are the second largest factor inhibiting their use.[26] To an extent, the Rohingya are justified in their skepticism. Prior to the 1990’s, Bangladesh used nonconsensual sterilization as a mechanism of population control to attain access to international aid. Though the international conversation surrounding reproduction shifted its focus towards reproductive rights following the 1994 UN International Conference on Population and Development, delivery of reproductive care in the global South is frequently characterized by lack of transparency and insufficient patient understanding of the risks and consequences of treatment. Additionally, women’s lack of control impacts follow-up care and long-term contraception. For example, when women seek the removal of implantable contraceptives, healthcare professionals often refuse to perform the requisite operation.[27] Patients must understand the risks of treatment in their own culture and circumstances where societal views, misconceptions, or fears may influence healthcare practices. Healthcare providers need to recognize the coercive potential they hold in their relations with patients and guard against breaches of patient autonomy in the delivery of treatment. In accordance with the principle of beneficence, healthcare providers treating refugees or individuals seeking asylum ought to abide by the same fiduciary responsibilities they hold toward citizens of the host state.[28] When patients show hesitancy or refusal toward treatment, healthcare providers ought to avoid achieving treatment by paternalistic practice such as “deception, lying, manipulation of information, nondisclosure of information, or coercion.”[29] Although well-intentioned, this practice undermines the providers’ obligation to respect patients’ autonomy.[30] The hesitancy of Rohingya women to accept some sexual or reproductive health care does not justify intentional lack of transparency, even when that treatment furthers their best health interests. However, paternalistic actions may be permissible and justified during medical emergencies.[31] Vl.     Informed Consent Respecting Rohingya women’s autonomy also places affirmative duties on healthcare providers to satisfy understanding and informed consent. However, language barriers and healthcare providers’ misconceptions about Rohingya religion and culture impede the achievement of these core conditions of autonomy for Rohingya women.[32] In an interview, a paramedic in Cox’s Bazar described the types of conversations healthcare providers have with Rohingya women in convincing them to accept menstrual regulation treatment, a method to ensure that someone is not pregnant after a missed period: “We tell them [menstrual regulation] is not a sin… If you have another baby now, you will get bad impact on your health. You cannot give your children enough care. So, take MR [menstrual regulation] and care for your family.”[33] This message, like others conveyed to Rohingya women in counseling settings, carries unvalidated assumptions regarding the beliefs, needs, and desires of clients without making a proper attempt to confirm the truth of those assumptions. Healthcare providers’ lack of cultural competence and limited understanding of Bangladesh’s national reproductive health policy complicates communication with Rohingya women. Additionally, the use of simple language, though recommended by the WHO’s guideline on Bangladesh’s policy, is inadequate to sufficiently convey the risks and benefits of menstrual regulation and other treatments to Rohingya women.[34] For informed consent to be achieved, “the patient must have the capacity to be able to understand and assess the information given, communicate their choices and understand the consequences of their decision.”[35] Healthcare providers must convey sufficient information regarding the risks, benefits, and alternatives of treatment as well as the risks and benefits of  forgoing treatment.[36] Sexual and reproductive health policies and practices must aim to simultaneously mitigate paternalism, promote voluntary and informed choice among Rohingya women, and foster cultural and political competency among healthcare providers. Vll.     Self-Determination Theory Self-determination theory is a psychological model that focuses on types of natural motivation and argues for the fulfillment of three conditions shown to enhance self-motivation and well-being: autonomy, competence, and relatedness.[37] According to the theory, autonomy is “the perception of being the origin of one’s own behavior and experiencing volition in action;” competence is “the feeling of being effective in producing desired outcomes and exercising one’s capacities;” and, relatedness is “the feeling of being respected, understood, and cared for by others.”[38] Bioethicists have applied self-determination theory to health care to align the promotion of patient autonomy with traditional goals of enhancing patient well-being. Studies on the satisfaction of these conditions in healthcare contexts indicate that their fulfillment promotes better health outcomes in patients.[39] Like principlism, self-determination theory in Cox’s Bazar could allow for increased autonomy while maximizing the well-being of Rohingya women and behaving with beneficence Fostering self-determination requires that healthcare professionals provide patients with the opportunity and means of voicing their goals and concerns, convey all relevant information regarding treatment, and mitigate external sources of control where possible.[40] In Cox’s Bazar, health care organizations in the region and the international community can act to ensure women seeking health care are respected and able to act independently. A patient-centered care model would provide guidelines for the refugee setting.[41] Providers can maximize autonomy by utilizing language services to give SRH patients the opportunity and means to voice their goals and concerns, disclose sufficient information about risks, benefits, and alternatives to each procedure, and give rationales for each potential decision rather than prescribe a decision. They can promote the feeling of competence among patients by expressly notifying them of the level of reversibility of each treatment, introducing measures for health improvement, and outlining patients’ progress in their SRH health. Finally, they can promote relatedness by providing active listening cues and adopting an empathetic, rather than condescending, stance.[42] Healthcare organizations ought to provide training to promote cultural competency and ensure that practitioners are well-versed on national regulations regarding sexual reproductive health care in Bangladesh to avoid the presumption of patients’ desires and the addition of unnecessary barriers to care. Increased treatment options would make autonomy more valuable as women would have more care choices. Given the historical deference to international organizations like the UN and World Bank, multilateral and organizational intervention would likely bolster the expansion of treatment options.  International organizations and donors ought to work with the government of Bangladesh to offer post-treatment comprehensive care and protection of women who choose treatment against the wishes of male community members to avoid continued backlash and foster relatedness.[43] CONCLUSION Rohingya women in Cox’s Bazar, Bangladesh face unique power relations that ought to be acknowledged and addressed to ensure that when they seek health care, they are able to act autonomously and decide freely among available options. While providers have duties under the principles of beneficence and non-maleficence, patient well-being is hindered when these duties are used to trump the obligation to respect patient autonomy. Current approaches to achieving sexual and reproductive health risk the imposition of provider and communal control. Self-determination theory offers avenues for global organizations, Bangladesh, donors, and healthcare providers to protect Rohingya women’s autonomous choices, while maximizing their well-being and minimizing harm. DISCLAIMER: As a male educated and brought up in a Western setting, I acknowledge my limitations in judgement about Rohingya women’s reproductive care. Their vulnerability and health risks can never be completely understood. To some extent, those limitations informed my theoretical approach and evaluation of Rohingya women's SRH care. Self-determination theory places the patients’ experiences and judgement at the center of decision-making. My most important contributions to the academic conversation surrounding Rohingya women are the identification of dilemmas where autonomy is at risk and advocating for self-determination. - [1] Hossain Mahbub, Abida Sultana, and Arindam Das, “Gender-based violence among Rohingya refugees in Bangladesh: a public health challenge,” Indian Journal of Medical Ethics (June 2018):1-2, https://doi.org/10.20529/IJME.2018.045. [2] “UN teams assisting tens of thousands of refugees, after massive fire rips through camp in Bangladesh,” United Nations, last modified March 23, 2021, https://news.un.org/en/story/2021/03/1088012#:~:text=The%20Kutupalong%20camp%20network%2C%20which,(as%20of%20February%202021). [3] Hossain et al., “Gender-based violence,” 1-2. [4] Benjamin O. Black, Paul A, Bouanchaud, Jenine K. Bignall, Emma Simpson, Manish Gupta, “Reproductive health during conflict,” The Obstetrician and Gynecologist 16, no. 3 (July 2014):153-160, https://doi.org/10.1111/tog.12114. [5] Margaret L. Schmitt, Olivia R. Wood, David Clatworthy, Sabina Faiz Rashid, and Marni Sommer, “Innovative strategies for providing menstruation-supportive water, sanitation and hygiene (WASH) facilities: learning from refugee camps in Cox's bazar, Bangladesh,” Conflict and Health Journal 15, no. 1 (Feb 2021):10, https://doi.org/10.1186/s13031-021-00346-9. [6] S M Hasan ul-Bari, and Tarek Ahmed, “Ensuring sexual and reproductive health and rights of Rohingya women and girls,” The Lancet 392, no. 10163:2439-2440, https://doi.org/10.1016/S0140-6736(18)32764-8. [7] Janet Cleveland, and Monica Ruiz-Casares, “Clinical assessment of asylum seekers: balancing human rights protection, patient well-being, and professional integrity,” American Journal of Bioethics 13, no. 7 (July 2013):13-5, https://doi.org/10.1080/15265161.2013.794885.; Christine Straehle, “Asylum, Refuge, and Justice in Health,” Hastings Center Report 49, no. 3 (May/June 2019):13-17, https://doi.org/10.1002/hast.1002. [8] Hossain et al., “Gender-based violence,” 1-2.; Schmitt et al., “Innovative strategies,” 10. [9] Audrey Schmelzer, Tom Oswald, Mike Vandergriff, and Kate Cheatham, “Violence Against the Rohingya a Gendered Perspective,” Praxis: The Fletcher Journal of Human Security, last modified February 11, 2021, https://sites.tufts.edu/praxis/2021/02/11/violence-against-the-rohingya-a-gendered-perspective/. [10] Schmelzer et al., “Violence Against.” [11] Schmelzer et al., “Violence Against.” [12] Liesl Schnabel, and Cindy Huang, “Removing Barriers and Closing Gaps: Improving Sexual and Reproductive Health and Rights for Rohingya Refugees and Host Communities,” Center for Global Development: CGD Notes (June 2019):6, https://www.cgdev.org/sites/default/files/removing-barriers-and-closing-gaps-improving-sexual-and-reproductive-health-and-rights.pdf. [13] Schnabel and Huang, “Removing Barriers,” 4-9.; Andrea J. Melnikas, Sigma Ainul, Iqbal Ehsan, Eashita Haque, and Sajeda Amin, “Child marriage practices among the Rohingya in Bangladesh,” Conflict and Health Journal 14, no. 28 (May 2020), https://doi.org/10.1186/s13031-020-00274-0. [14] Nuruzzaman Khan, Mofizul Islam, Mashiur Rahman, and Mostafizur Rahman, “Access to female contraceptives by Rohingya refugees, Bangladesh,” Bull World Health Organ, 99, no.3 (March 2021):201-208, https://doi.org/10.2471/BLT.20.269779. [15] Khan et al., “Access to,” 201-208. [16] Khan et al., “Access to,” 201-208. [17] Ramin Asgary, and Clyde L. Smith, “Ethical and professional considerations providing medical evaluation and care to refugee asylum seekers,” American Journal of Bioethics 13, no. 7 (July 2013):3-12, https://doi.org/10.1080/15265161.2013.794876.; Cleveland and Ruiz-Casares, “Clinical assessment,” 13-5.; Straehle, “Asylum,” 13-17. [18] Tom L. Beauchamp, and James Childress, Principles of Biomedical Ethics. Eighth Edition, (New York, NY: Oxford University Press, [1979] 2019), 219. [19] Beauchamp and Childress, “Principles,” 155.; Straehle, “Asylum,” 15. [20] Maria Persson, Elin C. Larsson, Noor Pappu Islam, Kristina Gemzell-Danielsson, and Marie Klingberg-Allvin, “A qualitative study on health care providers' experiences of providing comprehensive abortion care in Cox's Bazar, Bangladesh,” Conflict and Health Journal 15, no. 1 (Jan 2021):3, https://doi.org/10.1186/s13031-021-00338-9. [21] Rushdia Ahmed, Bachera Aktar, Nadia Farnaz, Pushpita Ray, Adbul Awal, Raafat Hassan, Sharid Bin Shafique, Md Tanvir Hasan, Zahidul Quayyum, Mohira Babaeva Jafarovna, Loulou Hassan Kobeissi, Khalid El Tahir, Balwinder Singh Chawla, and Sabina Faiz Rashid, “Challenges and strategies in conducting sexual and reproductive health research among Rohingya refugees in Cox's Bazar, Bangladesh,” Conflict and Health Journal 14, no. 1 (Dec 2020):83, https://doi.org/10.1186/s13031-020-00329-2.; Khan et al., “Access to,” 201-208. [22] Beauchamp and Childress, Principles, 102. [23] Ahmed et al., “Challenges and strategies," 6. [24] Ahmed et al., “Challenges and strategies," 7. [25] Beauchamp and Childress, Principles. [26] Khan et al., “Access to,” 201-208. [27] Kalpana Wilson, “Towards a Radical Re-appropriation: Gender, Development and Neoliberal Feminism,” Development and Change 46, no. 4 (July 2015):814–815, https://doi.org/10.1111/dech.12176. [28] Asgary and Smith, “Ethical and professional,” 3-12. [29] Beauchamp and Childress, “Principles,” 231. [30] Beauchamp and Childress, “Principles,” 231. [31] Beauchamp and Childress, “Principles.” [32] Beauchamp and Childress, “Principles.” [33] Persson et al. “A qualitative study,” 8. [34] Persson et al. “A qualitative study.” [35] Christine S. Cocanour, “Informed consent-It's more than a signature on a piece of paper,” American Journal of Surgery 214, no. 6 (Dec 2017):993, https://doi.org/10.1016/j.amjsurg.2017.09.015. [36] Cocanour, “Informed consent,” 993. [37] Richard M. Ryan, and Edward L. Deci, “Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being,” American Psychologist 55, no. 1 (Jan 2000):68-78. [38] Johan Y.Y. Ng, Nikos Ntoumanis, Cecilie Thøgersen-Ntoumani, Edward L. Deci, Richard M. Ryan, Joan L. Duda, Geoffrey C. Williams, “Self-Determination Theory Applied to Health Contexts: A Meta-Analysis,” Perspectives on Psychological Science 7, no. 4 (July 2021):325-340, https://doi.org/10.1177/1745691612447309. [39] Ng et al., “Self-Determination Theory.”; Nikos Ntoumanis, Johan Y.Y. Ng, Andrew Prestwich, Eleanor Quested, Jennie E. Hancox, Cecilie Thøgersen-Ntoumani, Edward L. Deci, Richard M. Ryan, Chris Lonsdale & Geoffrey C. Williams, “A meta-analysis of self-determination theory-informed intervention studies in the health domain: effects on motivation, health behavior, physical, and psychological health,” Health Psychology Review 15, no. 2 (Feb 2020), https://doi.org/10.1080/17437199.2020.1718529. [40] Leslie William Podlog, and William J. Brown, “Self-determination Theory: A Framework for Enhancing Patient-centered Care,” The Journal for Nurse Practitioners 12, no. 8 (Sep 2016):e359-e362, https://doi.org/10.1016/j.nurpra.2016.04.022. [41] Podlog and Brown, “Self-determination Theory.” [42] Podlog and Brown, “Self-determination Theory.” [43] Podlog and Brown, “Self-determination Theory.”  

Materialart: Online-Ressource

ISSN: 2691-4875

URL: Article

DOI: 10.52214/vib.v7i.8615

Sprache: Unbekannt

Verlag: Columbia University Libraries

Publikationsdatum: 2021

ZDB Id: 3046961-2

In: Voices in Bioethics, Columbia University Libraries, Vol. 8 ( 2022-06-10)

Kurzfassung: Photo by Jonathan Ford on Unsplash ABSTRACT Since 2008, an average of twenty million people per year have been displaced by weather events. Climate migration creates a special setting for a duty to rescue. A duty to rescue is a moral rather than legal duty and imposes on a bystander to take an active role in preventing serious harm to someone else. This paper analyzes the idea of expanding a duty to rescue to climate migration. We address who should have the duty and to whom the duty should extend. The paper discusses ways to define and apply the duty to rescue as well as its limitations, arguing that it may take the form of an ethical duty to prepare.  INTRODUCTION Climate migration creates a special setting for a duty to rescue. A duty to rescue is a moral rather than legal duty and imposes on a bystander to take an active role in preventing serious harm to someone else. Examples of circumstances range from person-to-person intimate rescue to saving those in poverty, even in distant parts of the world.[1] Since 2008, an average of twenty million people per year have been displaced by weather events.[2] Circumstances like being thrust from homes under the threat of fire, mudslide, and flooding vary greatly from long-term changes like land becoming too arid for crops or temperatures increasing annually gradually pushing up the number of heat-related deaths, with the area slowly becoming uninhabitable. Imminence in fleeing affects resettling and need for rescue with important implications for how the duty to rescue might apply. This paper reevaluates the ethical framing of the duty to rescue and, while it is arguably a stretch, applies it to climate migration.  Climate migration has become common and is expected to increase due to rises in sea level, increases in weather events that make areas uninhabitable, and changes to land that preclude farming or other necessary land uses. We argue that a duty to rescue may help highlight who has moral obligations to whom.  Because the problem is so large in scope, we suggest a change in the ethical limits to humans' duty to rescue other humans who are in distress. We imagine an expansion or extension of the duty to rescue to meet some of the basic needs created by climate migration. Yet how it should expand, and how much depend on ethical framing and practical limitations. l.     Expanding the Geographical Boundaries Two commonly recognized emergencies, Hurricane Katrina in the case of weather events and the current COVID-19 pandemic, provide a historical and current backdrop to evaluate ethical obligations as more disasters displace people. A significant reassessment of the ethical scope of an obligation to rescue in the case of weather events will be limited by the ability to render aid to those in distress in the case of a planet-wide weather catastrophe. The problems may overwhelm the ability to rescue or the reasonableness of attempting rescue. The extent of the moral obligation borne by humans to other humans in the case of a weather event has been largely defined by its locality and limited geographic influence. Whether we are imagining the scope of ethical obligation in the case of hurricane, flood, tornado, drought, or wildfire events, the perceived ethical obligation is significantly defined by the limited impact of these weather events on people outside the zone of the weather event's direct impact, yet close to that zone. A hurricane affecting New Orleans will not have immediate impact on the residents of California or even those on the northeast coast of the United States until a later time. Wildfires in the Pacific Northwest do not impair the ability of those in the rest of the country to come forward with assistance. But as climate migration crosses international borders, and climate events occur simultaneously in many regions, a more expansive duty to rescue may provide the ethical impulse to help those who live afar or migrate long distances.  In this respect, the need for help in the event of widespread climate migration due to global warming is more like a pandemic than a weather event. Its broad impact area diminishes the capability of nearly the entire balance of the human population to help due to those populations' awareness that they will, in short order, have the same need for the same resources, from the same cause. Those living near current flood zones may find their historically safe havens are also a flood zone. Those previously best positioned to rescue may find themselves also needing to relocate. Thus, we may observe the need for new rescuers. ll.     The Rule of Rescue The Rule of Rescue as defined by Al Jonsen describes the moral impetus or knee jerk reaction to save identifiable people facing death.[3] A duty to rescue has since been expanded beyond imminent death and beyond the near and identifiable. But there are limitations. For example, by most accounts, the ethical duty tends not to require extreme bodily risk or financial depletion. In comparing Good Samaritans to humanitarians, Scott M. James argues the duty to rescue arises from unique dependence, but the ethical obligation to help strangers through humanitarian aid is of a different nature.[4] The wrongness of failing to help is arguably more egregious when one is in a unique position to help. Like in the tragedy of the commons, where there is no unique positioning, when the global community is called upon to help, each individual in it may feel less obliged to do so. Climate migration falls in between—it requires helping strangers, yet it may move forward without anyone seeing themselves as uniquely positioned to help until those strangers become part of communities, at which time, there may be more moral justification to help a community member in need. Generally, arguments about Good Samaritans hinge on extraordinary acts, praiseworthy because they are acts of compassion, not obligation. Now all US states have Good Samaritan laws[5] which protect helpers from liability for help gone wrong or for a failure to succeed once engaged in an act of rescue. Extraordinary help as a moral good is thus somewhat encouraged through legal protection, but not imposed. Conversely, jobs like firefighting, search and rescue, and emergency medical care tend to oblige employees to take on risks that would be extraordinary if undertaken by the average bystander, yet they are rendered ordinary rescue as part of the job. Three states, Minnesota, Rhode Island, and Vermont have a broad duty to rescue, adding legal considerations to an otherwise moral conundrum. The laws do not require bystanders to take on risk for the sake of rescuing strangers.[6] The moral duty will require looking beyond law, but it is unclear how the moral duty to rescue should be distributed in the case of climate migration. A bare minimum would prevent taking advantage of newcomers, paying sub-minimum wage, and discriminating against them. Yet such a minimum is hardly rescue. lll.     An Ethical Rather than Legal Duty The difficulty in defining the duty to rescue as a legal obligation is that it is difficult to determine the extent of risk a rescuer ought to be required to take. The nature of this ethical duty is also arguably tied to the experiences of both the rescuer and the rescued. There are subjective aspects like what someone perceives as a danger that make it difficult to write enforceable laws requiring rescue. It is one thing to expect a rescuer to step into several inches of relatively warm water to lift a person lying face down in a pond and enable them to breathe. It is something altogether different to expect that rescuer to dive into frigid water and attempt to extricate someone trapped in a submerged automobile. As the legal philosopher H.L.A. Hart observed, it is always easier to define application of the core intention of any rule, whether law or ethical norm. It is more difficult to create legal certainty about how the law applies to what he described as “penumbra circumstances”. In the case of a hurricane, it is easier to define what surplus resources are available in areas geographically remote from the impact of the storm and demand, as a moral obligation, that those nearby but outside the area provide assistance. It is more difficult to obligate people, organizations, or governments to supply a quantity of medication or some number of ventilators to an adjacent community when they expect to imminently need them for their own community. In the early stages of climate migration, the ethics of extreme weather event assistance, a common application of the duty to rescue, will be useful and appropriate. The rising sea levels first experienced by island nations in the South Pacific[7] will not render those living in other coastal communities, those with greater available “high ground”, unable to supply resources to those in need. But when sea level rise and climate change affect more communities simultaneously, albeit in varying degree, the task of defining what response is ethically obligatory becomes increasingly complicated. Pinpointing the obligations of those communities which are resource rich to those communities which are resource deprived, and of those partly affected to those more severely affected may become necessary.  The limitations of the traditional duty to rescue could expand to meet the needs. lV.     Contribution to the Problem Many argue that the duty to rescue may depend on any appropriate claim of those needing rescue. One issue is whether preferential claims among those who can identify the source of the harm should call for a greater duty or whether everyone in need should be approached as like candidates for rescue, shaping the duty as equal across those on the receiving end. As climate change does have human-made causes, there are strong arguments to impose a greater ethical duty on any entity that caused the climate-related problems leading to the mass exodus. While the global north is often implicated in pollution that causes migration, industries like energy, transportation, and agriculture are tied to climate change and associated with significant greenhouse gas emissions.[8] Practices like directing agriculture to less sustainable single crop growth generally made land less farmable. Yet it is difficult to place blame and identify specific causal relationships as most migration is due to many factors. A movement toward greater accountability can be reframed as a greater duty to rescue, a duty to engage in the extraordinary. The fossil fuel industry, for example, should have a larger obligation than the average person. Similarly, some may argue anyone unjustly enriching themselves while contributing to climate change or people who over-consume have an elevated duty to rescue.[9] Climate change lawsuits demonstrate an eagerness to hold governments and corporations accountable, despite difficulty proving causation. V.     The Most Vulnerable One ethical dimension of climate migration that remains unexplored is how a duty to rescue applies to vulnerable populations who stand to be left behind or unable to migrate without assistance. Researchers from the Global North working across the Global South are increasingly observing the phenomenon of ethics dumping, where the research ethics of some countries are imposed on research subjects in other countries.[10] In that vein, rescuers should be careful not to impose unwelcome cultural standards or exploit people who are in the process of migrating. There is a gap in discussions reflecting voices that have been left out. The duty to rescue is incomplete without an attempt to understand the ethical experiences of those being rescued. The actual people affected by climate migration who are the least likely to have the means to migrate, or to do so without extreme hardship, should have a voice informing the global community including those in a position to carry out rescue. People who have the means and are young and healthy may easily make decisions to avoid the catastrophic consequences that climate migration brings. However, what about those who are left behind? For example, especially recognizing cultural differences, the homeless community, disabled community, refugees, the elderly community, and women[11] and children may suffer differently and call for more attention. In some parts of the world, human rights are severely constrained. An ethical duty to rescue, with many considerations and variables, may be more justified in the case of those most in need. As climate migration continues and increases significantly, it may be reasonable to ask the local and global community to focus on those least well positioned to migrate successfully. In this context, the use of phenomenology to understand the lived experiences of those migrating, sometimes termed “ethical experiences”, may help flesh out how a duty to rescue takes shape. The discussion of duty and obligation requires an articulation of the ethical experiences (how the local community in need of rescue views the proposed rescue).  Then, the obligation to interpret the duty as ‘one shall not’ or ‘one must’ can be focused on the migrants’ needs rather than the rescuers’ feelings of obligation.[12] A revised theory of the duty to rescue taking into account the asymmetrical experiences of communities involved could ensure that the needs of people whose living situations, gender, ethnicity, age, or race impact their ability to even begin the migration process are considered. In this discussion, the rescuing is directed toward communities /collectives of persons migrating, whether at once or across a period of time. Often, the climate migrant may not be in a state to articulate the nature of this event when it happens, given its subjective proximity. Yet, when communities are given the space and opportunity to articulate their shared values, the ethical action of rescue derives its meaningfulness from the community rather than the rescuers.  In other words, allowing climate migrants to explain their feelings can add complexity to what some see as a binary receiver-giver (of rescue) dynamic. This is necessary because the concept of vulnerable populations is fraught with problematic assumptions. There have been various definitions and criteria to determine what would constitute vulnerable populations.[13] For example, the United Nations Framework Convention on Climate Change[14] identifies and assesses vulnerable populations. These criteria may be helpful. However, they do not provide the full picture. Rather than identifying categorical criteria of vulnerable populations, engaging with people who are experiencing climate migration and listening to their current experiences and concerns helps determine need. Knowing what people need may prevent the kneejerk reaction to label people who are quite resilient yet have appropriate needs “vulnerable”. Proceeding with caution is important because the duty to rescue has hierarchical underpinnings of "us" an d "them." Often when people swoop in to save, there are good and bad consequences of the intervention. We should proceed with caution because often the helper misses the actual needs of those in need. The only way to combat this would be to make sure that people are empowered to inform those agencies that are able to help.  In addition to more practical approaches, large scale oral histories could allow those who have migrated already to share their experiences. It would be important to capture the lived experiences of people who are already experiencing the consequences of climate migration or of other migration like that due to political or economic extreme events. These experiences could shape our analysis of whether people in fact wish for rescue. If so, further conversations can determine best actions as well as give important insight into what resources might be necessary to empower people now and in the future.  Vl.     A Duty to Rescue as a Duty to Prepare If we view Good Samaritans as going above and beyond, then a duty to rescue, something ethically compelled, must bring rescue out of the framework of charity and place it in the context of humanity and obligations. Such a view would also support expanding the geographical reach of the otherwise more proximate duty. The duty may be stronger and take shape in a more workable way if it applies to preparing places expecting to see an influx of people due to climate migration and to helping those most in need. The duty may arise out of expectations of what type of community the place welcoming those migrating due to climate should be—does it want to offer good housing, schooling, and medical care as well as economic opportunity to new people? And if so, at what cost, or with which risks? If the newcomers are viewed as community members rather than strangers, a model of acceptance may lead to better preparation. Some considerations like whether the actions will reasonably help the persons in need of rescue[15] will shape the application of a duty to rescue in the context of climate migration. Similarly, ensuring that people have the chance to articulate their values may help communities support the newcomers. New relationships should not be defined as migrant and rescuer. Voluntariness in participation and not forcing any action deemed rescue would help ensure the human rights of those migrating. In the United States, President Biden issued an executive order addressing impending climate migration steeped in a duty to prepare by making plans for resettlement and to address the impact of climate migration.[16] Vll.     At What Risk? As we investigate the ethical obligations to meet even basic needs, we must also ask what level of risk is ethically compelled. There is an extraordinary need to integrate newcomers successfully, but it is difficult to stretch an ethical duty to rescue to require all the prerequisites for successful climate migration. Even defining success would create deep ethical arguments. As observed in almost all migrations, extraordinary charitable acts may be the key to success, while an ethical duty to rescue must try to require the important government and community-based basics and ensuring respect for human rights. That is, the migrating people should be rescued from circumstances that contradict basic human rights. Rather than comparing communities to bystanders, mere places where people will arrive and need to hash out how to find housing, jobs, education, and opportunity, a duty of preparation may be the key to rescue those disenfranchised by migration. There are cultural, personal, physical, psycho-social, and geopolitical issues surrounding how to best help those needing to permanently relocate. Ethics arguments will certainly range from “do nothing”, which may fail people, to “do everything”, which could waste taxpayer money in futile over-preparation while failing to actually help. Communities must avoid planning exclusively for one scenario only to have it not take place. Striking the balance, a duty to rescue as it could apply to climate migration should set goals of societal integration, and providing the basics like education, housing, food, health care, and job opportunity, the precursors to flourishing. Recommending the extraordinary, morally preferred but perhaps not compulsory, when charitable actors are participating, or when wrongdoers are compensating, may be more workable than seeing the duty to rescue as compelling people or local governments to take on significant financial and personal risk for newcomers. While humanitarian ethics supports helping everyone, it is likely that people who resettle in advance of a need to flee will find themselves with more choices and opportunities. Help is warranted for those with more dire needs. Preparing for them may do just that. Vlll.     Rescue Prior to Migration and Rescue in the Process of Resettlement The duty to enable the migration in the first-place hints to the inadequacy of a duty to prepare. The traditional duty to rescue perhaps steps in if rescue looks like those geographically just out of harm's way rescuing those in danger. That resembles the traditional moral requirement, or duty to rescue according to the Rule of Rescue. Humanitarian aid typically provided by many institutions makes sense and is in place, although financial support for additional humanitarian aid is always needed. Despite having moved to purportedly more capable communities, migrant communities may be able to develop more egalitarian orders of living.  Rather than continually being identified as having been rescued, it is important to make sure people keep or make social ties during and after migration.  Immigrants often face social isolation.[17] Small shifts in gestural language also have the potential to welcome people and show they are valued. For instance, some migrants may not like questions like “Where are you from?” and “What brings you here?” as they emphasize differences over fitting in. CONCLUSION The ethical duty to rescue should be expanded to better match those in need of relocation with a welcome environment and the resources needed to achieve success and fully integrate socially and culturally. Expanding a dialogue that includes the voices of people who have recently migrated whether due to violence, poverty, or climate, could properly frame the extent of the duty. If we are to apply the duty of rescue to climate migration, rescuers should avoid labeling people vulnerable, dependent, or needy, although there is reason to focus on those whose needs are the most dire. A soft duty to rescue people during the course of climate migration can come in the form of preparation. People will need help finding housing, education, access to food, and employment. Ultimately, to help them help themselves may be the best goal. While the obligations should be borne differently by people, whether due to a special responsibility, or a special relationship that creates a clearer duty, the global community must prepare for its role in rescuing those displaced by climate events. By helping those displaced at the start of the climate migration process according to a more commonly held notion of the duty to rescue, and by preparing to incorporate newcomers successfully according to an expanded duty to rescue, effectively a duty to prepare, countries that take on climate refugees may find themselves rewarded by the cultural diversity and workplace talents that people bring. A duty to those at a distance is a reasonable expansion of the duty to rescue. But what one ought to do in the global community varies somewhat from the traditional Rule of Rescue.  - [1] Singer, P. (1972). Famine, Affluence, and Morality. Philosophy and Public Affairs, 1(3): 229-43. [2] Irfan, U. (2022, March 16). Why We Still Don’t Yet Know How Bad Climate Migration Will Get. Vox. https://www.vox.com/2022/3/16/22960468/ipcc-climate-change-migration-migrant-refugee, citing the International Panel on Climate Change (IPCC) (2022). Sixth Assessment Report, Climate Change 2022, Impacts, Adaptation, and Vulnerability. https://www.ipcc.ch/report/ar6/wg2/  [3] McKie, J., Richardson, J. (2003) The Rule of Rescue. Social Science & Medicine, 56(12):  2407-2419. https://doi.org/10.1016/S0277-9536(02)00244-7. [4] James, S.M. (2007). Good Samaritans, Good Humanitarians. Journal of Applied Philosophy, 24(3):238-254. [5] Overview of Good Samaritan laws. https://worldpopulationreview.com/state-rankings/good-samaritan-law-states [6] Fifield, J. (2017, Sept. 19). Why It’s Hard to Punish ‘Bad Samaritans’. Stateline Blog, Pew Charitable Trusts, https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2017/09/19/why-its-hard-to-punish-bad-samaritans [7] Cassella, C. (2019). There’s a Climate Threat Facing Pacific Islands That’s More Dire Than Losing Land, Science Alert, https://www.sciencealert.com/pacific-islanders-are-in-a-climate-crisis-as-rising-sea-levels-threaten-water; Hassan, H. R., and Cliff, V. (2019). For Small Island Nations, Climate Change is not a Threat. It’s Already Here, World Economic Forum, https://www.weforum.org/agenda/2019/09/island-nations-maldives-climate-change/ [8] For example, Lyons, K. (2019). Australia Coal use is Existential threat to Pacific Islanders, The Guardian.  https://www.theguardian.com/world/2019/aug/12/australia-coal-use-is-existential-threat-to-pacific-islands-says-fiji-pm  [9] Cripps, E. (2013). Climate Change and the Moral Agent: Individual Duties in an Interdependent World. Oxford: Oxford University Press. [10] Schroeder, D., Chatfield, K., Singh, M., Chennells, R., and Herissone-Kelly, P.. Ethics Dumping and the Need for a Global Code of Conduct. In Cham. (Ed.)(2019). Equitable Research Partnerships. SpringerBriefs in Research and Innovation Governance. Springer.  2019. https://doi.org/10.1007/978-3-030-15745-6_1 [11] Giudice L.C., Llamas-Clark E.F., DeNicola N., Pandipati, S., Zlatnik, M.G., Decena, D.C.D., Woodruff, T.J., Conry, J.A. (2021). Climate Change, Women’s Health, and the Role of Obstetricians and Gynecologists in Leadership, International J Gynecol Obstet, 155(3), 345-356. 10.1002/ijgo.13958 [12] See Ferrarello, S. and Zapien, N. (2020). Ethical Experience: A Phenomenology, Bloomsbury. (for understanding phenomenological determinants of ethical action). [13] McLeman, R.A., Hunter, L.M., (2010). Migration in the context of vulnerability and adaptation to climate change: insights from analogues. Wiley Interdiscip Rev Clim Change, 1(3): 450-461. [14] Least Developed Countries Expert Group. (2018). Considerations Regarding Vulnerable Groups, Communities and Ecosystems in the Context of the National Adaptation Plans: United Nations Framework Convention on Climate Change. [15] Jecker, N.S. 2013. "The Problem with Rescue Medicine." J Med Philos, 38(1):64-81. [16] White House Report. (February 9, 2021), Executive Order (E.O.) 14013, “Rebuilding and Enhancing Programs to Resettle Refugees and Planning for the Impact of Climate Change on Migration.” (calls on the National Security Advisor to prepare a report on climate change and its impact on migration. “This report marks the first time the U.S. Government is officially reporting on the link between climate change and migration.” https://www.whitehouse.gov/briefing-room/presidential-actions/2021/01/27/executive-order-on-tackling-the-climate-crisis-at-home-and-abroad/ [17] Torres, J.M., Casey, J.A. (2017) The centrality of social ties to climate migration and mental health. BMC Public Health, 17: 600. https://doi.org/10.1186/s12889-017-4508-0

Materialart: Online-Ressource

ISSN: 2691-4875

URL: Article

DOI: 10.52214/vib.v8i.9680

Sprache: Unbekannt

Verlag: Columbia University Libraries

Publikationsdatum: 2022

ZDB Id: 3046961-2