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An increasing number of non‐governmental organisations (NGOs) provide humanitarian assistance, including healthcare. Some faith‐based NGOs combine proselytising work with humanitarian aid. This can result in ethical dilemmas that are rarely discussed in the literature. The article explores several ethical issues, using four generic activities of faith‐based NGOs: (1) It is discriminatory to deny aid to a needy community because it provides less opportunity for proselytising work. Allocating aid to a community with fewer health needs but potential for proselytising work is unjust, since it neither maximises welfare (utilitarianism) nor assists the most needy (egalitarianism). (2) Faith‐based‐NGOs may state that proselytising work combined with humanitarian assistance improves spiritual wellbeing and overall benefit. However, proselytising work creates religious doubts, which could transiently decrease wellbeing. (3) Proselytising work is unlikely to be a perceived need of the population and, if carried out without consent, breaches the principle of autonomy. Such work also exploits the vulnerability of disaster victims. (4) Governments that decline the assistance of a faith‐based NGO involved in proselytising work may deprive the needy of aid. Three strategies are proposed: (a) Increase knowledge to empower communities, individuals and governments; information on NGOs could be provided through an accessible register that discloses objectives, funding sources and intended spiritual activities. (b) Clearly demarcate between humanitarian aid from proselytising work, by setting explicit guidelines for humanitarian assistance. (c) Strengthen self‐regulation by modifying the Code of Conduct of the Red Cross to state criteria for selecting communities for assistance and procedures for proselytising work.
Non‐governmental organisations (NGOs) have undertaken a wide range of functions around the globe. Their agendas include humanitarian assistance, developmental aid, promotion of human rights and lobbying to protect the environment.1
The role of NGOs in provision of healthcare has continued to expand. Humanitarian assistance, defined as assistance given to meet the challenges of a humanitarian crisis, almost always includes provision of some type of healthcare, be it preventive action (such as providing shelter, clean water and sanitary facilities, immunisation against epidemics) or management of emergencies (such as injuries from a disaster). Programmes of developmental aid often integrate healthcare provision, in order to deal with the health‐related effects of underdevelopment. A more direct intervention is to contract out geographic areas or sections of health services to NGOs, a process endorsed and supported by international donors.2,3,4
It is difficult to state the number of active NGOs in a country, let alone internationally. In the year 2000, there were an estimated 26000 international NGOs, and the current number would be much higher.5 Short‐lived NGOs, which work specifically during a crisis with little accountability and disappear after the crisis, confound these estimates.
NGOs are not a homogeneous group, and an unknown proportion combine aid with political, social or religious agendas, such as proselytising work (that is, seeking the religious conversion of an individual or a group), aid for profit, and spreading the ideology of donor governments.1,2,6,7,8 There have been several reports of NGOs spreading religious faiths in poorer countries.6,7,8 The suspicion is deepened by the activities of certain religious groups working closely with NGOs. An example is the missionary efforts to target the “10/40 Window—the Muslim, Hindu and Buddhist nations between 10 degrees and 40 degrees north latitude”.7 Fragile states, natural disasters and conflicts offer an opportunity for these organisations to provide humanitarian assistance and conduct proselytising work, as illustrated by the report after the 2004 tsunami that “rage and fury has gripped this tsunami‐hit tiny Hindu village in India's southern Tamil Nadu after a group of Christian missionaries allegedly refused them aid for not agreeing to follow their religion … Jubilant at seeing the relief trucks loaded with food, clothes and the much‐needed medicines the villagers, many of who have not had a square meal in days, were shocked when the nuns asked them to convert before distributing biscuits and water”.8
These examples reveal potential conflicts of interest that arise when NGOs combine humanitarian work with proselytising work. It is important to explore these issues from the perspective of medical ethics, for three principal reasons. First, the role of NGOs in the health sector is becoming increasingly complex with the widening role of NGOs in failed states or disaster‐affected areas. Second, there is a growing number of NGOs with different agendas and little accountability. Some of them (such as faith‐based NGOs) combine proselytising work with humanitarian assistance, an emotive subject in many countries, with potential for conflicts of interest and ethical dilemmas. Finally, important ethical issues that arise are rarely addressed in the medical literature.
This article attempts to fill the gap. I begin by defining faith‐based NGOs and then use four generic situations that arise during their work to illustrate and explore ethical issues.
Faith‐based NGOs are those with strong links to religious organisations, either in their values, objectives or funding. They could be defined as NGOs that have one or more of the following characteristics: “Formal affiliation with a religious body; a mission statement or objectives with explicit reference to named religious values; financial support from religious sources and/or a governance structure where selection of board members or staff is based on religious beliefs or affiliations and/or decision‐making processes based on religious values” (italics added).5 The italicised words are emphasised for the following reasons: the formal nature of the affiliation needs to be specified because informal links and networks are common among NGOs and religious bodies; the mission statement per se may not capture the religious values of an organisation; and religious values need to be named because they often overlap with humanitarian values. For example, “provide spiritual support to the needy” expresses a universal value. However, the connotation is different if one says “provide Islamic spiritual support to those in need”.
Four situations are used to illustrate the ethical issues that arise when faith‐based NGOs combine humanitarian assistance and proselytising work. These are likely to reflect situations in poorer countries with dysfunctional or absent regulatory frameworks. The four situations are: selecting a community for assistance, implementing appropriate humanitarian assistance, carrying out proselytising work and the host government's response to proselytising work.
An NGO ready to provide humanitarian assistance in a country or region selects a community after considering several factors. Though the main factor is the community's needs for humanitarian assistance, others also play a crucial role in the decision: the competencies of the NGO to respond to the particular situation, the safety of its aid workers and the feasibility (eg, financial viability, geographic access). The Code of Conduct developed by the International Committee of the Red Cross is clear on this issue and states that the “humanitarian imperative comes first” and that “humanitarian aid will be given according to the need of individuals, families and communities”.9
Ethical issues can arise when certain population characteristics such as race, religion or caste are used to select a community for assistance. The second statement of the Code further reiterates this position by stating, “Aid is given regardless of the race, creed or nationality of the recipients and without adverse distinction of any kind. Aid priorities are calculated on the basis of need alone”.9
To look at another ethical issue, consider two communities in a country devastated by a natural disaster—community A, with a large population in serious need of healthcare, and community B, with a smaller population than A's and with fewer medical needs. Let us assume that a faith‐based NGO selects community B because it will allow proselytising work while A disallows it. Denying aid to the more needy community, A, is obviously discriminatory and violates the second requirement of the Code. Giving aid to community B violates the third requirement of the Code, that “aid will not be used to further a particular political or religious standpoint”. The other issue relates to allocation of resources. From a secular point of view, providing assistance to community B (which has fewer medical needs) does not maximise total welfare (utilitarianism) nor does it assist the most needy community (egalitarianism).10,11 In other words, scarce resources available to the NGO are not allocated using the principles of justice.
Faith‐based NGOs often use more subtle methods than this example. The following report from Aceh province in Indonesia after the 2004 tsunami illustrates this modus operandi:6
“I am not here to do relief work” said John a Malaysian Chinese lawyer … His calling was missionary work, he admitted. “They are looking for answers” he said of the disaster victims, whom he described as particularly good candidates for conversion. “Now we are befriending them, giving them food aid, clothes and stuff. We need to make friends with them first rather than telling them the concept of salvation. Long term that's where we are heading towards, to save their souls.”
This strategy also violates the third statement of the Code, in furthering a religious belief. The other ethical issue relates to autonomy and respecting the dignity of the person. In this example, proselytising activities were not a perceived need of the population (although there is a theoretical possibility of a community wanting specific spiritual assistance during a crisis). Therefore, by attempting to proselytise without the consent of the individuals or groups of individuals, the NGO is contravening the principle of autonomy.
After a community is selected for assistance, the NGO has to formulate and implement a package of appropriate interventions. A faith‐based NGO could argue that proselytising work and conversion to a particular faith enhances spiritual wellbeing and attacks the roots of evil and thereby improves overall benefit. This view is untenable for two reasons. First, the benefits of the intervention ought to be measured using the values of the recipients rather than of the NGOs. Few communities would consider it beneficial to endure proselytising work in the midst of a humanitarian crisis. Second, the process of proselytising begins by creating doubt or dissonance in existing beliefs or faiths. During this phase, the spiritual wellbeing (and therefore the health) of the recipient population may decline. Therefore, proselytising work in the aftermath of a disaster could worsen wellbeing in an individual or of a community already undergoing immense hardships.
A faith‐based NGO might plan its proselytising work only after selecting communities to receive aid. The Code of Conduct allows this with a caveat: “Notwithstanding the right of NGOs to espouse particular political or religious opinions, we affirm that assistance will not be dependent on the adherence of the recipients to those opinions. We will not tie the promise, delivery or distribution of assistance to the embracing or acceptance of a particular political or religious creed.”
The Indonesian example illustrates how aid workers of faith‐based NGOs aim to develop a special relationship and trust with the community before embarking on proselytising work. They do not violate the Code, as they do not directly link humanitarian assistance to proselytising work. However, is this ethical when one considers the asymmetric power relationship between the aid worker and a recipient? Having provided assistance at a time of dire need, the aid worker has considerable power over the individual and family. The faith‐based NGOs therefore will find it easy to convince individuals about their opinions or beliefs. On a larger scale, too, asymmetric power relationships arise when a faith‐based NGO negotiates with a government struggling to cope with a disaster or a distressed community. NGOs could also use their asymmetric power relationship and exploit the vulnerability of individuals or communities to further their own goals. An analogous situation is the power of doctors over their patients during clinical encounters, or the vulnerability of patients in the process of recruiting research subjects.12 Though there are several ethical principles relevant to these situations, in order to prevent the exploitation of patients and research subjects, there are no such guidelines to prevent the exploitation of vulnerable individuals by faith‐based NGOs. NGOs are obliged to take cognizance of the vulnerability factor and take special care to avoid exploitation of these communities.
Do the ethical issues raised against faith‐based NGOs apply to all NGOs? Yes. For example, the difference between faith‐based NGOs and government‐organised NGOs,1 or GONGOs, which further ideological or political agendas, is mainly in their specific objectives. At a conceptual level, they both use humanitarian assistance as a means to further religious or political objectives, often without the express consent of the victims of a crisis.
Governments that are required to respond to certain activities of NGOs also face ethical issues. Agreeing to allow faith‐based NGOs to operate frees much‐needed resources for use in other communities, and preventing them from providing humanitarian assistance could have catastrophic consequences. An extreme example is when a community requiring emergency healthcare does not receive aid because the government wishes to defend its principle of maximising welfare and allocating resources according to need. This would be a difficult decision to defend ethically, especially if there is an acute scarcity of resources to meet the health needs of the whole population. The government could request the faith‐based NGO to omit proselytising work and provide only humanitarian assistance. This transfers the responsibility of resolving an ethical dilemma to the NGO, which has to decide whether to provide only humanitarian assistance or withdraw services. (The second strategy outlined in the section below addresses this area.)
Policy options to prevent or attenuate the sort of situation described in the previous section are discussed in the next few paragraphs. The most obvious strategy would be to try to demarcate the humanitarian roles from proselytising work. This assumes a degree of self‐regulation by the faith‐based NGOs. The examples of Aceh Province and Tamil Nadu also illustrated how the host state and the recipients were placed in a vulnerable position, because of an asymmetry of power. Therefore we need further methods to strengthen the autonomy of vulnerable individuals, communities and governments.
One strategy is to provide adequate information so that public and governments could be empowered to make informed decisions about whether to allow, restrict or disallow the work of NGOs. For this purpose, the public requires adequate knowledge of their goals, objectives and functions. This requires a coordinated effort, and neither individuals nor governments can work in isolation and succeed. One policy option therefore is for an international institution (such as the World Health Organization or the United Nations Development Programme) to develop a voluntary NGO register. This ought to be a requirement, especially when NGOs wish to work across national borders. The register could take the form of those established on the internet for randomised clinical trials, such as the US government site at http://www.clinicaltrials.gov.
The register should include information on goals, principal sources of funding, relationship to principal donors or faiths, spiritual conduct and areas for humanitarian assistance. With time, the credentials of the listed NGOs could be confirmed by the feedback received from host countries, individual recipients and other NGOs. A humanitarian ombudsman could also perform this function.13 Though this is not a foolproof system, it is a step in the right direction in order to reduce asymmetry of information.
A second strategy is for individual countries to develop guidelines for accepting humanitarian assistance. Explicit statements or regulations on the characteristics of NGOs allowed to work and the scope and limitations of humanitarian assistance could be developed. This will prevent conflicts between faith‐based NGOs and governments. Ideally these regulations should be reached by consensus. They could be based on the Code of Conduct of the International Committee of the Red Cross and developed after wide consultation within and among countries. Conflicts that arise during the work of NGOs and governments (eg, the scenario described in the section Responses by governments to the work of faith‐based NGOs) could be referred to the humanitarian ombudsman.
The third strategy is for the Code of Conduct to be suitably modified and for NGOs to abide by them voluntarily.9 Because religion has become such an emotive issue in the world today, one could dedicate a separate section of the Code to address issues relating to faith‐based NGOs. I suggest three modifications to the Code.
The Code should include a requirement that NGOs provide basic information to their clients and communities. Specific examples could be given as to how and when to disseminate such information. Ideally, the information ought to be provided before the NGO begins work in a community, maybe in the form of information leaflets.
The Code should give NGOs more explicit directions on the procedures to follow when selecting communities for assistance. After a disaster, distressed victims are rarely capable of articulating their needs. Most would not be aware of health needs such as prevention or immunisation. In such instances, it is often their government that requests assistance on their behalf. On many occasions when governments are overwhelmed by the magnitude of the crisis, donors, altruistic individuals or NGOs select communities on the premise of best interests. The events after the tsunami of 2004 provide an example, when a large number of charities and individuals organised themselves to provide assistance to the needy. The selection of needy communities for humanitarian assistance relies on the altruism of persons or organisations and the benevolence of governments. One cannot expect this unsystematic method of selection to be comprehensive and without bias. Certain communities may be bypassed as a result of their religion, race or locality. A more prescriptive method ought to be included as a section in the Code. One option is to focus on a fair process to select communities (ie, procedural justice) rather than on production of just outcomes.11 The ingredients of a fair procedure could include the following: the main factors for selecting a community to be the expressed needs of the communities and whether the NGO has the capacity to meet these needs (ie, resources, logistics and capabilities). These factors ought to be evaluated separately and independently of other factors, which might be called “extraneous”. An example of an extraneous factor is when a charitable individual or donors to an NGO request that their donation be used for a particular activity or a particular population group (such as a specific religious group). The situation after the tsunami illustrated this when altruistic individuals and charities selected devastated villages or towns for a number of reasons such as familiarity (eg, it was close to their home town), or guilt felt by survivors. Under such circumstances, the fair procedure should be, first, to prioritise the communities to receive aid using the main factors; and then to inform all stakeholders (eg, the host country, the communities and individuals receiving aid) of the extraneous factors that the NGO wishes to consider. For example a faith‐based NGO could clearly states that “our charity provides assistance to orphans of Christian parents”. Communities and governments ought to have the right to decline aid from such organisation without threats of sanctions or denial of aid by other NGOs. However, it would be wrong for NGOs to deny humanitarian assistance because of race, religion, caste, social status or ethnicity (for example it is not acceptable for NGOs to state that “our organisation does not give assistance to Muslim villages”).
The statement giving NGOs the right to “espouse particular political or religious opinions” should be modified to include the process to be adopted when espousing such opinions or conducting proselytising work. This is because providing information alone (as spelt out in my first recommendation for change) cannot mitigate the vulnerability of the recipients of humanitarian assistance. Proselytising work would be fair only after obtaining consent specifically for it. From whom and how consent should be obtained needs to be specified. In the case of a group of vulnerable persons (eg, displaced populations in a camp), consent may be required from a group rather than individuals. Though that practice could be criticised as impractical, individual vulnerabilities foster interdependence and a shared sense of autonomy among individuals. Obtaining consent from a group instead of individuals also poses problems because it may not necessarily mean that individuals have the power to consent. Therefore the process of obtaining informed consent must be specified and consist of at least three essential steps: providing adequate information, ensuring it is understood, and ensuring that the recipients agree freely to the faith‐based interventions. This is similar to obtaining consent from volunteers for medical research.14 Finally, the point at which consent to do proselytising work must be obtained is also important. Consent ought to be obtained after the programme of humanitarian assistance has been completed, in order to minimise pressure on vulnerable communities and individuals to accept a different faith or to feel compelled to do so out of gratitude.
This article highlights several ethical issues that can arise when faith‐based NGOs combine proselytising work with humanitarian assistance (which includes healthcare). Further exploration of these issues and discussion of strategies are urgently required.
I wish to thank Prof S Holm for his valuable comments on the initial draft.
NGO - non‐governmental organisation
The author is currently a member of the Board of Trustees of an NGO in Sri Lanka.
The author is based at the Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Kynsey Road, Colombo 8, Sri Lanka. He is currently on sabbatical leave and working as a locum consultant physician, Barking, Havering and Redbridge Hospitals NHS Trust, Essex, UK.