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Should Humanitarian Hearing Healthcare Providers Be Concerned about Ethical Practices? Part One: Need for Continued Engagement

Clark, Jackie L. PhD

doi: 10.1097/01.HJ.0000430597.63711.fb

Dr. Clark, coeditor of the Audiology Without Borders column, is a clinical associate professor at the University of Texas at Dallas, a research scholar at University of the Witwatersrand in Johannesburg, and chair of the International Society of Audiology Humanitarian Committee.

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Figure. Fi

Moral excellence comes about as a result of habit. We become just by doing just acts, temperate by doing temperate acts, brave by doing brave acts.”—Aristotle

Many common threads are found amongst humanitarian hearing healthcare professionals. Without a doubt, one of the most prevalent is the desire to sacrificially provide professional services to those who otherwise would not have access. Some of those services may involve raising awareness about ear disease and hearing loss; identifying individuals with disabling hearing loss; providing hearing aids or cochlear implants; performing surgery; establishing educational programs for deaf and hard of hearing students and their families; and training community healthcare workers, medical technologists, or physicians who live locally.

Humanitarian work can take place within one's own country of residence or outside of a humanitarian's home borders. We have a joke whenever we are at the work site that “what happens during our humanitarian work STAYS there.” Of course it is humorously meant to refer to instances such as which volunteer snores, who belongs to THOSE undergarments, a certain team member's hygienic practices, a sleep talker's confessions, and, on those other occasions, the shared tears of frustration from the tremendous need of the community that can be emotionally overwhelming.



Various guidelines detail accountability within one's own licensing jurisdiction about what is legal, ethical, and/or professional. Legally acceptable behavior is defined through state or federal/national laws, while codes and regulations are those that one abides by to maintain professional licensing. Some professional organizations have spent a great deal of time and effort defining scope of practice and accepted standards of care, as well as establishing ethical guidelines for their members to refer to when questions arise about professional conduct and behavior.

Most frequently, these legal and ethical guidelines are established to keep the safety of the general public foremost and to ensure professional integrity so that the public will maintain confidence in the profession. But, there sometimes is a blurring of what can and cannot be ignored for professional accountability and ethical standards of care when outside of licensing borders. Clearly, when volunteering professional skills outside of one's licensing body's purview, there can be room for confusion.

Some say that ethics and morality can be considered the same concept. Morality is considered “knowing” and ethics, “doing” what is right, good, just, fair, noble, and so on. In relational ethics, or ethics related to caregiving, there is value and respect for the community, including professionals, researchers, consumers, and families, with an inherent reliance upon reciprocal compassion and empathy. It is unsurprising that actions based upon mutual respect can often result in long-term friendships as trust bonds become established and secured between the community served and humanitarians. When questions of morality/ethics arise, one can relate to the expression, “I cannot define ‘it’ but know ‘it’ when I see ‘it’ being corrupted.”

Not only are professionals continually updated through professional education opportunities about their ethical responsibilities and conduct within their licensing jurisdiction, but the community being served has mechanisms to lodge complaints or concerns that could result in a professional's license being revoked. Despite the laudable and sacrificial actions, hearing healthcare programs can still find themselves facing ethical dilemmas when away from the humanitarian's home governing body.

Here's a specific example of a conflict of ethics in humanitarian healthcare practices:

After some negotiation with a foreign (noncitizen) humanitarian team captain, the Minister of Health in developing country XYZ is happy to welcome provision of 1,000-4,000 instruments (cochlear implants or hearing aids) at no cost to the deaf and hard of hearing recipients over a one- to two-week time period by the foreign humanitarian team within the boundaries of country XYZ. There has been no strategic long-term plan discussed by the Minister of Health for the humanitarians to return 30-45 days (nor even one year or more) following the dispensing of such a large quantity of instruments. The minister is just happy to have these instruments brought to his country.

If this scenario were to occur within the jurisdiction of the humanitarian's governing body, there would be a number of grave concerns, despite the approval from one government official. Returning to the notion of relational ethics discussed above, this scenario on surface level would seemingly appear to provide great value at no or little cost to the community by lavishly dispensing a large quantity of instruments to those in need. However, when examining the absence of a strategic plan or the engagement of local hearing healthcare professionals in the enterprise, it is questionable whether reciprocal compassion and empathy for the community exist. We know that when dispensing hearing aids and cochlear implants, there must be immediate and long-term commitment on-site to address initial fitting problems or program mapping (in the instance of cochlear implantation).

Additionally, though we recognize that there is an extreme shortage of hearing healthcare professionals, a genuine attempt, out of professional courtesy, should be made to include and collaborate with hearing healthcare professionals in developing country XYZ. In the absence of hearing healthcare professionals in country XYZ, there is a benefit of searching for and enlisting hearing healthcare professionals in nearby countries. It would stand to reason that when the inevitable instrument failures or necessary modifications have to occur, the nearest hearing healthcare professional will be voluntarily or involuntarily enlisted to handle the impending problems from such a massive undertaking.

Pofessionals practicing in developing countries have reported instances where instruments from a large dispensing project were given to individuals who already had working and appropriate equipment that they had previously purchased. Had the local/nearby professionals been apprised of the program, they would have been able to notify those deaf and hard of hearing individuals who may be in remote areas and unaware of the program. So why not recognize nearby hearing healthcare professionals and ensure that they know the goals of the program and that the foreign team is aware of the local health priorities?

Moreover, by including the Minister of Education in the program, a positive impact could be achieved for a strategically implemented educational program of those deaf and hard of hearing children newly fit with instruments. In the scenario described above, not only are the best interests of the general community placed in a compromised situation, but also the integrity of the profession is called into question by the community and other professionals who work and reside within that community when the impending and predictable problems occur with the instruments.

The second part of this series will discuss what to do when encountering a remote and unserved rural community in need, and where to look for help in navigating ethical dilemmas in humanitarian hearing healthcare.

Reprinted with permission from ENT & audiology news: Clark JL. Should humanitarian hearing healthcare providers be concerned about ethical practices? 2011;20(2):60-62. © Pinpoint Scotland Ltd - All Rights Reserved.

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Audiology Without Borders

Our Audiology Without Borders column, featured each month in the HJ eNewsletter, highlights humanitarian hearing healthcare programs.

The column is edited by active humanitarians Jackie Clark, PhD, and King Chung, PhD. Dr. Clark is a clinical associate professor at the University of Texas at Dallas and a research scholar at University of the Witwatersrand in Johannesburg; and Dr. Chung is an associate professor of audiology at Northern Illinois University in DeKalb.

Let us know about your humanitarian program! Send the details to—manuscripts should be about 1,000 words, and photographs are also welcome (300 dpi in jpg, tif, or gif format).

Read past Audiology Without Borders columns in a special collection at

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