This edited volume from Ayesha Ahmad and James Smith offers an expansive tour across the difficult landscape of ethical conundrums in humanitarian action, traversing issues related to “moral distress,” triage and treatment of mental health and Ebola patients, cross-border health provision, humanitarian failures, and humanitarianism's place in the neoliberal global order. The volume's seventeen chapters are diverse, addressing ethical decision-making, offering reflections on the ethics of practice, and taking ethical stances from the perspectives of practitioners and academics. The ethical dilemmas the contributors tackle are individual as well as structural, arising out of both personal experience and extensive research. The chapters are loosely organized into themes that focus on organizational issues; humanitarian responses to specific crises (including the European refugee “crisis,” the Syrian conflict, and Haiti); mental health responses; gender-based violence; and the political economy of the humanitarian system. Ethical reflections about the provision of healthcare repeatedly appear, and represent the strongest and most comprehensive theme of the book.

The diversity of chapters usefully highlights a series of often-neglected topics that are deserving of concerted ethical reflection in humanitarian response. For example, chapter 14 discusses the invisibility of sexual violence directed at men and the ethics of classifying some acts of sexual violence against males as torture, which exacerbates its overall underreporting. Chapter 13 examines the ethics of disclosure in relation to gender-based violence, suggesting that in some circumstances requiring individuals to verbally acknowledge this violence may represent a form of coercion. Other chapters deconstruct the role and motivations of volunteers (particularly with regard to the European refugee crisis and the ethics of “voluntourism”) and the moral distress that afflicts humanitarian workers, often long past their deployment and return home.

A number of engaging chapters explore the tensions between various approaches to health and humanitarian action and their intersection with current debates. For example, chapter 12 analyzes the conceptual frameworks that guide practitioners providing mental health and psychosocial support, looking at how these frameworks engage with notions of vulnerability. Using a composite case study from Syria, the authors compare the potential implications of treatment that is attentive to individual rights with those of a treatment emerging from a focus on the “public good.” In the case of the former, the focus on conceptions of vulnerability places attention on women and children as the most vulnerable populations, whereas in the latter, the focus is on treatment of the husband/father since he is the one considered responsible for the health of the entire family. Such tensions intersect with current conversations about vulnerability and the provision of culturally appropriate mental health services in emergency contexts.

Other chapters engage, in differing ways, with issues of power in the humanitarian system. Chapter 10 explores the ethics of including foreign actors and excluding the state, using the humanitarian response to the Haitian earthquake as a backdrop for examining questions of efficiency and accountability and how these questions are shaped by history and local context. Chapter 17 asserts an “ethic of refusal” for principled humanitarians to adopt for use against the “philanthrocapitalism” of the donor foundations that both respond to and create inequality in the world. Both chapters reflect topics of current debate in the humanitarian sector: the former deals with issues of local humanitarian action and the latter with the role of the private sector in humanitarian response.

The expansive breadth of the volume is both its strength and its corresponding weakness. The editors explicitly state in the final chapter that they accepted all submissions to the volume. While I appreciate this open approach, the results are somewhat uneven. Some chapters are clearer than others in their intent and focus, and even in their engagement with the ethical questions that they raise. And while some chapters narrate stories and ethical dilemmas, others advocate ethical positions that are closer to moral stances. In a few chapters, ethics appears as a friendly acquaintance instead of a serious relationship.

An analytical framework could have provided an overarching coherence to the volume, supplemented with succinct introductory sections preceding the themes implicit in the volume's organization. This approach could have highlighted recurrent themes, such as the professionalization of the humanitarian response or the tensions between medical ethics and a holistic response. Each of the editors respectively provides an introduction and an afterword that picks up on the plurality of the book's “encounters with ethics” (p. 1), but these chapters offer little in the way of recommendations for the humanitarian sector as a whole beyond a call to engage in further ethical reflection.

The editors’ decision not to refuse any contribution is itself the subject of ethical reflection as well. In his closing chapter, Smith writes briefly about this choice, underscoring that some perspectives in the volume are “underrepresented in mainstream discourse” and acknowledging the “profound injustices” (p. 309) that are visible from this choice and the inherent power of authors and editors to shape our understanding of events. He gives the example of including in the volume a chapter in which the authors—all Israeli medical officials—write about the ethical dilemmas of first providing care in Israel to patients injured on the Syrian side of the Israel-Syria border and later “voluntarily returning” them to Syria. Smith recognizes that their perspective is not juxtaposed by the narratives of the Syrian patients themselves and writes that “despite six chapters related either directly to the ongoing conflict in Syria, or to the mass displacement that followed, Syrian contributors are notably underrepresented as authors in their own right” (p. 310).

Even as some perspectives are absent, many of the chapters provide thought-provoking assessments based on the lived experience of working in or researching the multifaceted dimensions of humanitarian response, and as such give voice to its profound quandaries. Overall, Humanitarian Action and Ethics it is a welcome addition to the annals of reflection on the ethical dilemmas inherent in responding to humanitarian crises.