Ethics and Disasters

Patricia ReynoldsDirector, Bishopric Medical Library

Sarasota Memorial HospitalSarasota, FL

Ethics and Disasters: a topic of epic proportions

• Disasters and emergencies are:– International and local– Multicultural, multi-ethnic, multi-religious– Environmental and man made– Involve governments, NGO’s, corporations, victims,

workers, and the press– Ethics implications are at the core of preparation,

policies, response and recovery

Ethics and Disasters

• What is a disaster?• Why do we need to know the ethical basis of

disaster preparation and response?• What is special about disasters that motivates

people to act and respond ethically? How is this manifested?

• What are the relevant ethical principles that form the basis of our actions and reactions?

What is a Disaster?• “A disaster is an event (or series of events) that harm or kills a significant

number of people or otherwise severely impairs or interrupts their daily lives in civil society. Disasters may be natural or the result of accidental or deliberate human action. Disasters include, but are not limited to, fires; floods ; storms; earthquakes; chemical spills; leaks of, or infiltration by, toxic substances; terrorist attacks by conventional, nuclear or biological weapons; epidemics; pandemics; mass failures in electronic communications; and other events that officials and experts designate “disasters””

• “Disasters always occasion surprise and shock; they are unwanted by those affected by them, although not always unpredictable. Disasters always generate narratives and media representations of the heroism, failures and losses of those who are affected and respond.”

Zack, N. (2009). Ethics for disaster. Lanham, Maryland: Rowman & Littlefield Publishers, Inc.

Emergencies

• Emergencies are typically local and can be dealt with local resources

• Emergencies are typically of a shorter duration • A declaration of a state of emergency is

usually done for disasters – not emergencies.

Our Social Contract

• “Government has an obligation, based on the justification of its origins, to prepare citizens for survival in second states of nature caused by disaster. Such preparation requires implementation through public policy.” John Locke

• These rights are presumed in the US Declaration of Independence and protected by the first ten amendments of the constitution.

Zack, N. (2009). Ethics for disaster. Lanham, Maryland: Rowman & Littlefield Publishers, Inc.

What is special about disasters that motivates people to act and respond ethically?

• Basic human values of – Compassion, – Empathy, – Respect for dignity of others– Professional codes of conduct– “There but for the grace of God, go I”– More??

Ethical theories and ethical principles

• Ethics is not about what is - but what should be.– Ethical relativism: morality varies between people and

societies according to their cultural norms – Universalist or objectivist moral theories: fundamental

principles that are invariant through out time and space. “People have a basic right to safety and it is a fundamental obligation of all governments to ensure

that their citizens are protected to a reasonable degree from known risk, and that citizens are informed and warned of any risks known to governmental officials that threaten public safety.”

“To respect the equal dignity of all human beings, recognizing a basic right to life and subsistence” “The condemnation of coarse public sector corruption” “The obligation to respect human autonomy”

The Search for Principles of Disaster Management. Etkin D, Davis I,

Relevant Ethical PrinciplesSubstantive Principles• Individual liberty• Protection of the public

from harm• Proportionality• Privacy• Duty to provide care• Reciprocity• Equity• Trust• Solidarity• Stewardship

Procedural Principles• Reasonable• Open and transparent• Inclusive• Responsive• Accountable

“Stand on Guard for Thee. Ethical considerations in preparedness planning for pandemic influenza”. A report of the University of Toronto Joint Centre for Bioethics Pandemic Influenza Working Group. 2005

General Ethical Principles

• Solidarity• Joint responsibility• Non-discrimination• Humanity• Impartiality• Neutrality• Co-operation• Territorial sovereignty• Prevention• Fairness• Respect for person• Limiting harm• Role of the media

History of Ethics in Medicine and Healthcare

Hippocratic Oath – classic 1 I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my witnesses, that I will fulfill according to my ability and judgment this oath and this covenant:• To hold him who has taught me this art as equal to my

parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art—if they desire to learn it—without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but no one else.

• I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.

• I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art.

Hippocratic Oath – classic 2• I will not use the knife, not even on sufferers

from stone, but will withdraw in favor of such men as are engaged in this work.

• Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves.

• What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about.

• If I fulfill this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot. Translation from the Greek by Ludwig Edelstein. From The Hippocratic Oath: Text,

Translation, and Interpretation, by Ludwig Edelstein. Baltimore: Johns Hopkins Press, 1943.

“Ethical Directives for the Practice of Medicine 1”Encyclopedia of Bioethics 3rd ed. Post, Stephen G. 2004

• Encyclopedia of Bioethics 3rd ed. Post, Stephen G. 2004– 4th century B.C.E – Early 20th century

Oath of Hippocrates 4th century B.C.E. Oath of initiation Oath of Asaph Advice to Physician 17 Rule of Enjuin Five Commandments and Ten Requirements 1617 A Physician’s Ethical Duties from Kholasah al Hekman Daily Prayer of a Physician (prayer of Moses Maimonidies) 1793 Code of Ethics AMA 1847 Venezuelan Code of Medical Ethics, National Academy of Medicine 1918

“Ethical Directives for the Practice of Medicine 2” Encyclopedia of Bioethics 3rd ed. Post, Stephen G. 2004

• Declaration of Geneva, World Medical Assoc 1948

• Intl Code of Medical Ethics 1949• Principles of Medical Ethics AMA 1957• Declaration of Professional Responsibility:

Medicine’s social contract with humanity AMA 2001

• Charter on Medical Professionalism (2002) ABIM, ACP, etc

• Code of Ethics, Am Osteopathic Assn 1998• Code of Ethics and Guide to Ethical

Behaviour of physicians.Canadian Medical Assoc 1996; New Zealand Medical Assoc. 2002

• Chile – 1983• Brazil - 1988• Norway – 2000• Japan 1991

• Oath of Soviet Physicians 1971• Solemn Oath of a Physician of Russia

1992• Regulations on Criteria for Medical

Ethics and their Implementation – China – 1988

• Ethical and Religious Directives for Catholic Health Facilities 1971 – rev. 2001

• Health Care Ethics Guide, Catholic Health Assoc. of Canada 1991

• Oath of a Muslim Physician, Islamic Medical Assoc. of North America 1977

• Islamic Code of Medical Ethics, Kuwait Document, Islamic Organization for Medical Sciences 1981

Global Ethics• Human Rights first explicitly declared internationally in 1948 in the United

Nations’(UN’s) Declaration of Human Rights. – Not an international law – global paradigm

• United Nations Charter• Health for All in the 21st Century” World Health Organization (WHO)• 1985 Tokyo Declaration by the World Medical Association against physicians being

involved in torture• 1988 United Nations Resolution, the “Right to Intervene”• International Humanitarian Law (IHL) (IHL comprises the Geneva Conventions and the

Hague Conventions)• The Helsinki Declaration protects the patients’ rights and integrity with regard to

research. Ethics Landmark but not practical for disasters• endorsed at the General Assembly of the World Medical Association in Helsinki,

Finland in 1964

HEALTH DISASTER MANAGEMENT Guidelines for Evaluation and Research in the Utstein Style Chapter 8: Ethical issues. Prehosp Disast Med 2002;17(Suppl 3):128–143.

Professional codes of ethics

• “Professions governed by Codes of Ethics approved by their members function on the assumption that these codes will not be violated in practice. When they are violated, practitioners may be guilty of malpractice, incurring criminal as well as civil and professional, penalties”

Zack, Naomi Ethics for Disaster, 2009 Rowman & Littlefield Publishers.Series: Studies in Social, Political, and Legal Philosophy

Complex timesExportation of hazards constitutes an ethical issue and also, from time to time, a legal issue. Bhopal Famine in Africa

Solidarity• Deliberate and freely chosen unity among certain, groups

or populations. This presupposes the awareness of unity and the acceptance of the consequences of unity. “When referring to healthcare, solidarity means the obligation to share the financial risks of illness and handicap with others not necessarily of one’s own social group.”

• “Solidarity of interests is based on the principle of reciprocity: people share risks that are common to each other”

• The principles of solidarity will be particularly applicable to memorandums of understanding with local organizations.

Joint Responsibility and Non-discrimination

• Joint responsibility– Emergency management is not solely the domain of emergency

management agencies; rather, it is a shared responsibility between governments, communities, businesses and individuals.

• Non-discriminationNon-discrimination Principles of the Law (FEMA)http://www.fema.gov/iv-non-dscrimination-principles-law– Federal civil laws rights in Section VI of this Guide require equal

access for, and prohibit discrimination against, people with disabilities in all aspects of emergency planning, response, and recovery. To comply with Federal law, those involved in emergency management should understand the concepts of accessibility and nondiscrimination and how they apply in emergencies.

The Guiding Principles on Internal Displacement

The Guiding Principles seek to protect all internally displaced persons in internal conflict situations, natural disasters and other situations of forced displacement

Unanimously adopted by The UN Commission and the General Assembly Internally displaced persons shall enjoy, in full equality, the same rights and freedoms under international and domestic law as do other persons in their country. These Principles shall be applied without discrimination of any kind, such as race, color, sex, language, religion or belief, political or other opinion, national, ethnic or social origin, legal or social status, age, disability, property, birth, or on any other similar criteria.Certain internally displaced persons, such as children, especially unaccompanied minors, expectant mothers, mothers with young children, female heads of household, persons with disabilities and elderly persons, shall be entitled to protection and assistance required by their condition and to treatment which takes into account their special needs.

Hurricane Katrina, New Orleans

http://www.brookings.edu/about/projects/idp/gp-page

Impartiality• The American Red Cross, as a member of the International

Red Cross and Red Crescent Movement, adheres to the Fundamental Principles of the International Red Cross and Red Crescent Movement. http://www.redcross.org/portal/site/en/menuitem.d229a5f06620c6052b1ecfbf43181aa0/?vgnextoid=f5195032f953e110VgnVCM10000089f0870aRCRD&vgnextchannel=d18859f392ce8110VgnVCM10000030f3870aRCRD

• Specifically, the Principle of Impartiality states, “It makes no discrimination based upon nationality, race, religious beliefs, class, or political opinions. It endeavors to relieve the suffering of individuals, being guided solely by their needs, and to give priority to the most urgent cases of distress.”

Red Cross

Code of Conduct for International Red Cross

• The Code of Conduct for International Red Cross and Red Crescent Movement and NGOs in Disaster Relief was drawn up in 1992 by the Steering Committee for Humanitarian Response http://en.wikipedia.org/wiki/Steering_Committee_for_Humanitarian_Response to set ethical standards for organizations involved in humanitarian work. In 1994, the SCHR http://en.wikipedia.org/wiki/SCHR adopted the code and made the signing of it a condition for membership in the alliance.

• 492 Signatories as of now - 2012

Standard of Care 1

• What is the meaning of “standard of care”?• How did Hurricane Katrina affect our understanding

of the ethical implications of Standard of care?• How is the concept of triage affected by crisis

standards of care?• What are the legal implications of crisis standards of

care ?

Standard of Care 2• The Standard of Care is a case- and time-specific analytical process in medical

decision-making, reflecting a clinical benchmark of acceptable quality medical care. This benchmark, which is used to evaluate and guide the practice of medicine, encompasses the learning, skill and clinical judgment ordinarily possessed and used by prudent health care providers or payors of good standing in similar circumstances.

• The standard of care must reflect the art (consensus of opinion of clinical judgment) and science (published peer reviewed literature) of medicine and must be uniform for all health care personnel whether they are providing direct clinical care or reviewing the medical necessity of past, present or future medical care.

• A violation of standard of care may result in under-utilization of medical care, but also occurs when unnecessary care (over-utilization) is provided.

• The standard of care has a national and clinical basis, rather than a local provider community or payor review basis.

American College of Medical Quality, policy 3 http://www.acmq.org/policies/policies3and4.pdf

Crisis Standards of Care

• 2009 – Institute of Medicine and the AHRQ sought national public input in creating a unified standard of care for disaster and emergencies.

• Originally called Altered Standards of Care – changed to Crisis Standards of Care for legal reasons

Crisis Standards of Care: Summary of a Workshop Series 2009http://iom.edu/Reports/2009/Crisis-Standards-of-Care-Summary-of-a-Workshop-Series.aspx

Recommendations 1:• Develop consistent state crisis standards of

care protocols with 5 key elements– A strong ethical grounding– Integrated and ongoing community and provider

engagement, education and communication– Assurances regarding legal authority and involvement– Clear indicators, triggers and lines of responsibility– Evidence based clinical processes and operations

IOM: Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report 2009

http://www.iom.edu/~/media/Files/Report%20Files/2009/DisasterCareStandards/Standards%20of%20Care%20report%20brief%20FINAL.pdf

Recommendations 2:• Seek community and provider engagement

– special attention should be given to vulnerable populations• Adhere to ethical norms during crisis standards of care.

– Conditions of overwhelming scarcity limit autonomous choices for both patients and practitioners regarding the allocation of scarce resources, but do not permit actions that violate ethical norms

• Provide necessary legal protections for healthcare practitioners and institutions implementing crisis standards of care

• Ensure consistency in crisis standards of care implementation– Triage teams, etc , Palliative care, Mental health support,

Attention to vulnerable populations, Real time information sharing

• Ensure intrastate and interstate consistency among neighboring jurisdictions

Institute of Medicine• Guidance for Establishing Crisis Standards of Care

for Use in Disaster Situations – Letter Report 2009• Crisis Standards of Care: A Systems Framework for

Catastrophic Disaster Response -2012– vital templates to guide the efforts of

professionals and organizations responsible for CSC planning and implementations

– http://www.iom.edu/Reports/2012/Crisis-Standards-of-Care-A-Systems-Framework-for-Catastrophic-Disaster-Response.aspx

IOM: Continuum of incident care

“Crisis Standards of Care”

A Community Conversation

Disaster” Defined

What do disasters have in common? How do disasters differ?• People’s needs exceed

available resources• Help cannot arrive fast

enough

• Some are long-lasting and widespread (flu pandemic)

• Others are sudden and geographically limited (earthquake, terrorist attack)

Preparing for Disasters: The Challenge

• Disasters can lead to shortages of critical medical resources

• Shortages require hard decisions, for example—• Who should be at the front of the line for vaccines or antiviral

drugs?• Which patients should receive lifesaving ventilators or blood?

• In extreme cases, some people will not receive all of the treatment they need

How do we give the best care possible under the worst possible circumstances?

Recent Examples

Hurricane Katrina• Hospital overload

H1N1 Pandemic• Vaccine shortage

The Response: “Crisis Standards of Care”

Guidelines developed before disaster strikes—

To help healthcare providers decide how to administer...

THE BEST POSSIBLE MEDICAL CARE

…when there are not enough resources to give all patients the level of care they would receive under normal circumstances.

When Might We Need Crisis Standards of Care?

• Extreme Crisis– Hurricane– Flu Pandemic– Earthquake– Bioterrorism

• Scarce Medical Resources– Blood– Ventilators– Drugs– Vaccines– Staff

How Are Crisis Standards of Care Different?

Focus of Normal Care

Focus of Crisis Care

Possible Reasons for Crisis Standards of Care

– To make sure that critical resources go to those who will benefit the most

– To prevent hoarding and overuse of limited resources

– To conserve limited resources so more people can get the care they need

– To minimize discrimination against vulnerable groups– So all people can trust that they will have fair access to

the best possible care under the circumstances

Possible Strategiesto Maximize Care Space

Put patient beds in hallways, conference rooms, tents

Use operating rooms only for urgent cases Supplies

Sterilize and reuse disposable equipmentLimit drugs/vaccines/ventilators to patients

most likely to benefitPrioritize comfort care for patients who will die

StaffHave nurses provide some care that doctors

usually would provideHave family members help with feeding and

other basic patient tasks

When there isn’t enough to save everyone… how should we decide who gets what?

Some options--1. First-come, first-served? 2. Lottery?3. Save the most lives possible by giving more

care to people who need it the most?4. Favor certain groups?

The old OR the young?Healthcare workers and other emergency responders?Workers who keep society running (utility workers,

transportation workers, etc.)?

Where Do You Come In?

Community Conversations help policy makers:

• Understand community concerns about the use of limited medical resources during disasters

• Develop crisis standards of care guidelines that reflect community values and priorities

Preparing for Disaster

Crisis Standards of

Care (“CSC”)---a piece of the puzzle

The Deadly Choices at MemorialBy SHERI FINK Aug 25, 2009 New York Times

Which of the following ethical considerations do not apply to the Pou case1. Informed Consent2. Immunity for healthcare workers3. Palliative care4. Allocation of scarce resources5. Neutrality

What type of evacuation triage was set up in Memorial?

1. Sickest first2. Lottery3. Sickest last 4. Random selection

Ethical Principles Applied Prior to Disasters

• Introduction of prevention measures

• Importance of good quality healthy environment

• Education, training and awareness raising

• Participation – public input at national and local level

• Freedom of expression• Access to justice• Disaster prevention at the

workplace

• Disaster prevention in recreation and tourist areas

• Disaster prevention in public places – schools and hospitals

• Special prevention measures for the most vulnerable groups

• Organization of and participation in emergency drills

• Preventive evacuation of populations

Ethical Principles on Disaster Risk Reduction and People’s Resilience, Prieur M. European and Mediterranean Major Hazards Agreement (EUR-OPA)http://www.coe.int/t/dg4/majorhazards/ressources/pub/Ethical-Principles-Publication_EN.pdf

Preparing for different types of disasters

• Pandemics• Natural disasters• Burns, bombs and explosions• Biological• terrorism

Preparations• Random Selection – Lottery

• As part of the preparation, planning must occur before a disaster to help alleviate any influences by immediate pressures that could cloud moral judgment.

• The planning must be general in scope, but not too general that morally or factually is vacuous.

• The planning ought to express our best moral principles and not go against them and be practical and possible to execute.

• Make the plan optimistically and not violate existing moral principles.

Community Strategy for Pandemic Influenza Mitigationhttp://www.globalsecurity.org/security/library/report/2007/pr015-09.htm

Ethical Approach to Allocation of Scarce Resources and Triage

• Fairness – inherently just to all individuals• Duty to care duty to steward resources– Duty to attempt to obtain best outcome for the greatest number of

patients with available resources – does not mean save the most lives – a comfortable death may be a good outcome.

• Transparency • Consistency • Proportionality• Accountability Hick JL, Hanfling D, Cantrill SV. Allocating scarce resources in disasters: emergency department principles. Ann

Emerg Med. 2012 Mar;59(3):177-87. Epub 2011 Aug 19. Review. PubMed PMID: 21855170.

Public Health Decision Making• Concerned with populations rather than individuals• Utilitarian: greatest good for the greatest number• Public health interventions must be necessary and effective to

address the public health issue based on currently available information

• Public health authorities must use least restrictive alternative intervention available

• Benefits and burdens of public health decisions should be distributed equitably among society: “equitable distribution”

• Need for a fair process and transparency in decision making

Principles of Allocation• Principle of social worth – people who have instrumental value –

healthcare workers, government, etc• Random Selection – Lottery• Principle of fair chances – anyone needing resources gets them until they

run out• Allocations based on age, overall health or disability – seeks to maximize

quality life years• Life Cycle principle – child would receive preference• Allocate resources to those most likely to survive to hospital discharge• Sickest first

– Resources may be used on those most likely to die

ADA and Rehabilitation Act• Value judgments about the worth

and quality of human life have the potential to play prominent roles in allocation decisions.

• Disabled citizens, because of their special needs and compromised health status have a greater potential for catastrophic outcomes.

• State and Federal legislation directs public health and emergency officials to take the needs of disabled explicitly into account when planning for public health emergencies.

Wendy F. Hensel & Leslie E. Wolf, Playing God: The Legality of Plans Denying Scarce Resources to People with Disabilities in Public Health Emergencies Florida Law Review - 2011

Legal Mandates• Titles II and III of the Americans with Disabilities

Act and § 504 of the Rehabilitation Act broadly preclude discrimination against people with disabilities on the basis of their impairments.

• All public hospitals and service providers are covered under Title II of the ADA, which precludes states, local governments, and their agents from discriminating against qualified individuals with disabilities in the provision of any service, program, or activity.

• The regulations define discrimination to include providing ―an aid, benefit, or service that is not as effective in affording equal opportunity to obtain the same result, to gain the same benefit, or to reach the same level of achievement‖ as that provided to people outside of the protected class.

• The regulations also prohibit the imposition or application of eligibility criteria that screen out or tend to screen out an individual with a disability or any class of individuals with disabilities from fully and equally enjoying any service, program, or activity, unless such criteria can be shown to be necessary for the provision of the service, program, or activity being offered.

• The Stafford Act enforces non discrimination on grounds of race, color, religion, nationality, sex, age and disability

Reasons for excluding disabled in algorithms

– Individuals will need resources for prolonged period of use

– They are deemed to have a poor quality of life post-treatment

– They have a limited long term prognosis as a result of their disabilities

– The same exclusions that might apply to non-disabled may affect the disabled: neuro and cognitive impairments, etc

Ethical Principles Applied During Disasters 1

• Humanitarian assistance• Information and

participation during disasters

• Compulsory evacuation of populations

• Respect of dignity• Respect of persons• Emergency assistance for

the most vulnerable persons

• The importance of rescue workers

• Measures to safeguard and rehabilitate the environment

• Necessary measures to safeguard and restore social ties

Ethical Principles on Disaster Risk Reduction and People’s Resilience, Prieur M. European and Mediterranean Major Hazards Agreement (EUR-OPA)http://www.coe.int/t/dg4/majorhazards/ressources/pub/Ethical-Principles-Publication_EN.pdf

Ethical Issues During a Pandemic

• Health workers continue to provide care during a communicable disease outbreak

• Restricting liberty – quarantine• Allocation of scarce resources – e.g. vaccine• Global governance: travel advisories

Ethical Principles Applied after Disasters 2

• Strengthening resilience to the effects of disasters

• Protection of economic, social and cultural rights

• Protection of civil and political rights

Who will request or need Ethical Information such as this?

• Hospital emergency management committees• Bioethics committees• Public Health agencies and departments• Local emergency management command centers, to include

Police, Fire, EMS• Physician and nursing education opportunities• Presentations to local Nursing homes and Assisted Living

facilities, etc.• Presentations to local faith based and minority organizations

Community Organizations Active in Disaster

• The purpose of the Sarasota COAD is to advocate for and promote a coordinated countywide disaster preparedness planning initiative that aims to integrate human services agencies and faith-based organizations into the county’s disaster preparedness system. The initial focus of the committee is to support the design and adoption of standardized disaster plans that ensure common response goals and written coordination and communication procedures, linking those agencies to the county’s Comprehensive Emergency Management Plan (CEMP).

Special Thanks• Naomi Zack, PhD for permission to use her book on our web

site• Staff at DIMRC: Cindy Love, Siobhan Champ-Blackwell• Staff at MLA: Debra Cavanaugh and Jenny Pierce• Stephanie Bauer, Ph.D. Univ. of Alaska, Anchorage• Most especially, Barbara Folb