Ethical Issues in Disaster Medicine




Medical practitioners and health officials train for decades to provide run-of-the-mill health services. How should their choices change in times of disaster, that is, during “a serious disruption of the functioning of a community or a society involving widespread human, material, economic, or environmental losses and impacts, which exceeds the ability of the affected community or society to cope using its own resources”?


This definitional inability to cope without outside help creates a strong moral imperative for health workers, officials, and ordinary citizens from societies near and far to pitch in and help. This obligation is a matter of humanity, and sometimes justice, as well as prudence. For some health workers and officials, including many local ones, helping in a disaster is part of their job.


Fortunately, people often accept the duty to assist those in a disaster, even across international borders. Donations pour in. Our “rescue mentality” inclines us to strive to save identified endangered life, especially during a discrete event, even at great cost. The question is how to use that aid wisely and ethically—and how to prevent and prepare for disasters in the first place.


Historical perspective


Toward the end of the twentieth century, two cultural processes affecting disaster response ethics have taken shape. Until that time, bioethics writing had relatively little to say on disasters. , Nowadays, a number of professional societies and international organizations have specific (sections of) documents on disaster management, as do a number of U.S. states. Second, the HIV/AIDS epidemic ushered in a paradigm change to public health culture in America and elsewhere. An earlier emphasis on collective health interests was replaced by emphasis on personal liberty, nonstigmatization, and checks on public health authorities’ powers. For example, quarantine, which used to be a staple intervention for containment of infections, is now used only esoterically, often during disasters. , Legal culture now substantially constrains the ability of public health officials to surveil disease and to mandate reporting and disclosure of disease status, again making disasters the exception.


We have relatively new documents to address events that have newly become rarer in the culture of public health surrounding them. How do these documents conceive of disaster ethics? How should we conceive of it?




Current practice


Disaster ethics affects conduct during the prevention, mitigation, and planning stages ( Section 1 ). It also affects many dilemmas that arise during disaster response, especially about altered standards of care, informed consent, triage, disparities, quarantine, surveillance, research, transparency and communication, rescuers’ rights, and political involvement ( Section 2 to Section 11 ). Finally, it affects choice in the recovery process ( Section 12 ).



Prevention, Mitigation, and Planning


A less fortunate side of our rescue mentality is that our inclination to act before disaster events is weaker. , But it is wiser and more ethical to try to prevent disasters by stemming the vulnerabilities that lead to them (e.g., through safely built nuclear reactors), mitigate them (e.g., through building codes and zoning laws that mitigate the effects of future earthquakes and flooding, as well as insurance to minimize their economic effects), and plan the response, once a disaster becomes inevitable (reducing the adverse effects of disaster, e.g., through public announcements; stocking up on medications, equipment, food, etc.; and training first responders and other health personnel for effective, coordinated disaster response). Some advance processes can take decades, for example, creating command chains, comprehensive guidelines, and legal frameworks for effective response, and fully training health personnel, which is a shared responsibility of medical educators and the personnel. ,


Advance preparation is as important for optimizing ethical decision making during a response as it is for optimizing medical and logistical components: “Ethical rules defined and taught beforehand should complement the individual ethics of physicians.” Moreover, rapid ethical consulting and support can preempt health worker stress, which might otherwise later occasion unethical choices, as allegedly happened in Memorial Hospital during Hurricane Katrina in 2005. It can also prevent accidental active harm by health workers: inadequate training may have contributed to the many unnecessary amputations (example courtesy of Michael Southworth) that aid workers performed following the 2010 Haiti earthquake. Advance preparation permits international organizations to tailor their general plans respectfully toward local circumstances and cultures. It also permits coordination across centers, organizations, and jurisdictions, increasing both efficiency and equality.



Altered Standards of Care


Sections 2–11 focus on ethical questions that arise in disaster response. These are some of the most dramatic questions in medical ethics: Are clinicians allowed to help each patient below the standard of care or without informed consent, just to save resources and time for others? How should one ration life-saving ventilators during an avian flu pandemic? How should one decide equitably which area to protect next from spreading fire? When is it permissible, or mandatory, to force people into quarantine, to shut schools, or to evacuate an area? What are the limits of permissible surveillance, mandatory testing, and other potential transgressions of privacy? What kinds of medical trials are legitimate on vulnerable disaster victims? How should one communicate risk to a frightened public responsibly yet with ample transparency and opportunity for feedback? Do health workers deserve added protections or instead have duties to take on major personal risks? How should aid organizations balance their avowed neutrality with the urge to act for patients in political and legal battlegrounds?


The present subsection addresses the common expectation that responders, seeking to be free to help more patients, will provide less intense care per patient than is standard in normal times. One way to put this is by calling for “crisis standards of care,” defined as “a substantial change in usual health care operations and the level of care it is possible to deliver, which is made necessary by a pervasive (e.g., pandemic influenza) or catastrophic (e.g., earthquake, hurricane) disaster.” Altered practices don’t just include allegiance to special algorithms and to a command hierarchy, with less plurality and more coordination than in ordinary practice. They also require greater resource stewardship, and hence reduced resource investment per patient. This can and should be avoided up to a certain point by, for example, using stockpiles and added volunteers, by repurposing patient care areas, by extending the efficacy of existing personnel (say, by cutting required administrative and clinical procedures per patient and by assigning each more patients), and by conserving, adapting, substituting, and occasionally reusing supplies. , But there can come a point when the combined medical need of services is so high that a choice must be made: standard care for some, or seriously altered care for many more. At that point, the ethical choice is usually the latter.


Some disagreement exists about expressing an altered standard through legal statutes. However, with rare exceptions, experts agree on the legitimacy of some radical alterations to expectations from caretakers in a disaster. Even opponents of altered standards of care agree that “creating algorithms to equitably and rationally allocate scarce resources is necessary and appropriate.”


Such radically altered care practices are often defended as part of the transition in disasters from focus on one’s own patient’s care to maximizing the number of patients serviced and lives saved overall: “the guiding principles for health care delivery during catastrophes may shift from autonomy and beneficence to utility, fairness, and stewardship.” They could also be defended as a matter of equality: providing something to everyone is more equal than privileging only some.


The legitimacy of radically altered care raises the question whether there is any minimum to the quality of care that can be provided. Alternatively, does the acceptable level always depend on the opportunity cost in terms of other patients’ needs? Some authors and the SPHERE project insist that even in the worst disasters, there is always a minimum standard that must be kept, defined in terms of, for example, a certain number of gallons of water per person or a certain health service, such as trauma care. On the other hand, the very definition of disaster is that not all services can be dispatched. In battlefield triage and certain disaster triage systems, some wounded patients are tagged as “black” (or, in some systems, “blue”), that is, too terminally wounded for scarce medical support, trauma care included.


What remains constant even in disasters is human dignity; in fact the need to acknowledge patients’ dignity may only increase. When patients are “black” or “blue,” some dignity and respect remain important, which could be expressed in different ways: palliation and sedatives, separation from other patients, or some consent and privacy rights. This is part of the reason why certain ordinary patient rights should always be safeguarded. ,



Informed Consent


It is generally recognized that “a public health disaster such as a pandemic, by virtue of severe resource scarcity, will impose harsh limits on decision-making autonomy for patients and providers.” The value of provider allegiance to special algorithms and to a chain of command has already been mentioned. But part of the altered standard affects patient autonomy. According to the World Medical Association, “the most appropriate treatment available should be administered with the patient’s consent. However, it should be recognized that in a disaster response there may not be enough time for informed consent to be a realistic possibility.” Some decisions that affect the patient’s health and welfare, such as triage and, for some, mandatory quarantine (see the following discussion), do not require consent at all—although if time permits, they are best explained to the patient and performed with his or her informed consent.


The point can be summed up as follows: In a disaster, when a certain care decision must take place with great expediency (either for the patient’s sake or in order to move quickly to treat others), ethics requires less by way of patient consent than in normal times (legality will change with jurisdictions). In decisions affecting only the patient’s own health (e.g., amputation of an infected foot, evacuation from a dangerous area), some consent or assent remain necessary unless the patient is decisionally incapacitated and proxies are not available. Given the time constraints, fully informed consent generally remains unnecessary. Decisions about a patient’s care that substantially affect the health of others (e.g., vaccination, isolation) do not require the patient’s fully informed consent, yet some form of consent or assent may remain necessary if the intervention is intrusive. Even when informed consent is unnecessary, it usually remains important to be transparent and to disclose pertinent information such as treatment follow-up steps and any underlying triage principle, if only in hindsight.



Triage


“Triage is a medical action of prioritizing treatment and management based on a rapid diagnosis and prognosis for each patient.” At various points in the disaster response process, not all patients who could benefit from medical assistance can receive it. Even if all could receive one type of assistance (say, full medical attention for postexposure psychological stress after having watched many hours of television coverage), that would take too many resources away from other services. Planned, sensible, and coordinated triage can keep these decisions expedient, rational, and fair.


Triage decisions are often difficult for health personnel, who usually define themselves as their patient’s staunch advocates yet find themselves making hard choices between patients. Perhaps as a result, “many recent disaster responses have been characterized by a general lack of meaningful triage” (see Chapter 54 ). Following blast events there is a documented tendency to categorize patients with major soft-tissue injuries as highest priority, even when they lack internal bleeding and critical injuries, which can come at the expense of patients with critical injuries who could have otherwise been saved. To keep triage as expedient, rational, and fair as possible, it helps to plan standard triage practices and train in them and/or delegate them to professionalized triage teams.


Triage Methods


But how to triage? Many methods are in current use. Some triage methods categorize patients into several levels of urgency—most commonly (1) immediate priority (color-coded red), (2) must wait (yellow), (3) least severe injuries, or the “walking wounded” (green), and (4) prognosis so poor that there is no justification for spending limited resources on them (black; or black or blue) (see Chapter 54 ). Other methods consist of instructions, such as the following:




  • Provide assistance first to patients with the highest improved incremental survival, or (more widely) to those who stand to benefit most from assistance, medically or overall.



  • Provide assistance first to the most vulnerable people, or to those with the greatest or most “urgent” need, or to the worse off, medically or overall, currently or usually.



  • Provide assistance first to patients who are first in line (first-come-first-served).



  • Provide assistance first to response personnel, such as some health workers and police.



  • Provide assistance as ordained by a fair lottery.



How to decide between all these methods? One way to do so is according to the fundamental goals that triage purports to serve.


Fundamental Goals Behind Triage


What is the point of triage efforts? What are the methods described methods for ? If you will, what would count as success in a triaging method?



  • 1.

    Utilitarianism: One fundamental approach to judging triage is utilitarian. Utilitarianism is the ethical theory that we should maximize collective welfare. For some, utilitarianism ought to govern disaster triage, and triage has sometimes been defined as necessarily utilitarian: “Triage is the utilitarian sorting of patients into categories of priority to rationally allocate limited resources; it is, proverbially, to do ‘the greatest good for the greatest number.’ ” (see Chapter 54 ).


    In disaster triage, utilitarianism could be understood to demand maximizing the number of lives saved, or that of the life years saved, or that of the quality-adjusted life years (QALYs) saved, or simply the welfare saved. It is especially common to understand utilitarianism to support saving the most lives. However, “disaster impacts may include loss of life, injury, disease, and other negative effects on human physical, mental, and social well-being, together with damage to property, destruction of assets, loss of services, social and economic disruption, and environmental degradation.” Saving lives is not the only relevant (health) metric from the utilitarian viewpoint of maximizing collective welfare. Clearly some of the attention of utilitarian emergency personnel should go to other matters: to helping radiation victims not only accomplish short-term survival but also live as long as possible; to minimizing amputation-related disabilities or, indeed, mental morbidities; and to helping “psychologically traumatized individuals who do not require treatment for bodily harm but might need reassurance or sedation if acutely disturbed.” Some utilitarians would add that when the quality of life for a sufficient number of patients or enough life years are at stake, these considerations can trump a slightly greater chance of saving a single patient’s life for a short period. Even when the relevant disaster triaging is for life support, some have proposed “explicitly adding considerations of ‘maximizing life-years saved’ to ‘saving the most lives,’ ” which, they hold, “yields a more complete specification of accomplishing the greatest good for the greatest number.”


    Whether in terms of life saving or longevity, health, and welfare more broadly, questions remain as to which triaging method utilitarianism would support. Color-coding seems suitable (more so for a utilitarian approach that restricts itself to maximizing lives saved, and less for ones focused on other metrics). On the face of it, so is providing care to patients with the highest prospect of treatment benefit. But on the rare occasions in which admission or diagnosis is very long and resource intensive, utilitarianism may support even first-come first-served or a fair lottery, arbitrariness notwithstanding, due to their extreme expediency. Utilitarianism may also be thought to lend support to prioritizing response personnel, because a response worker is instrumental to the effort to assist many patients. Helping a single one of these other patients would help patients less, even if that single patient stands to benefit more from immediate help than the worker does (see the Response Worker Prioritization section).


  • 2.

    Egalitarianism: Another fundamental approach to judging triage methodology is egalitarian. Egalitarianism (from the French égal , meaning “equal”) is an ethical theory that values equality and therefore places at least some weight on increasing or expressing equality. Egalitarians, when deciding triage levels, do not always decide in favor or the patient who stands to benefit the most from the treatment. When a patient stands to benefit only a little more than others would, but they are much worse off than he or she is, egalitarians may decide in their favor.


    Egalitarianism comes in many variants. As a fundamental approach behind disaster triage, it may demand greater equality in survival or, depending on its variant, in longevity, lifetime health (expressed in, e.g., QALYs), or welfare, or greater equality in the prospects or capabilities for them. Alternatively, it can demand equalizing service availability and quality (or prospects or capabilities for them ), or it can demand that the system express equal concern and respect for all in other ways.


    In our context, egalitarianism may support giving some priority to patients and populations who are (momentarily or usually) relatively worse off, medically or overall. Depending on the exact variant of egalitarianism, the resulting limited priority may go to patients whose contemporaneous prognosis is dire (because their medical prospects are now poor), to patients who have lived with serious disabilities for years (because their lifetime health is worse), to young patients (because dying now would make them short-lived), to socioeconomically disadvantaged patients (because their welfare prospects and resources are lower), or to those who queued up first (because first-come first-served may be thought to express equal concern).


  • 3.

    Proceduralism: A final fundamental approach to judging triage emphasizes the process of decision making. Proceduralism emphasizes certain preferred procedures : impartial and nondiscriminatory decisions; transparency about triage criteria and deliberation with stakeholders, including socially marginalized groups, about those criteria; and use of fair lotteries. Proceduralism is not directly concerned with outcomes , such as the number of lives saved or the equality of benefit distribution across populations.


    A worry about focusing on procedures for triage decision and not on what these decisions should be is that preferred procedures can still lead to misguided triage. A fair lottery can recommend very wasteful and inegalitarian triage, as can deliberation with stakeholders. However, some proceduralists believe that using the right procedures also tends to select the best procedures, at least in the long run. This seems plausible with regard to some procedural considerations, such as the prohibition on any personal relations between triage officers and the patients being triaged. Emergency physicians should not make triage decisions about people to whom they are partial, including even their own patients (so decisions about continued ventilator support or continued surgery after initial laparotomy should usually be handled by other doctors). One reason that partiality would be wrong is that it is a recipe for making biased triage decisions. However, it is less clear how other preferred procedures necessarily enhance the quality of triage decisions in the long run, and whether disaster is the time to act in the light of speculative long-term benefits.



Disability Weights, Age Weights, and Discrimination


A startling implication of one potential fundamental goal mentioned, that of maximizing health or QALYs, is that people living with a chronic condition are deprioritized for life-saving treatment, say, for ventilators during influenza pandemics. The reason is that saving each such person is expected to produce fewer QALYs and less health per annum than saving a similar person who is expected to remain healthy. Another implication is that older and/or terminal patients, whose remaining life expectancy tends to be lower than that of healthier, younger patients, should usually be deprioritized. The emergency preparedness documents of some U.S. states embrace similar triage practices. One states, “There are reasons to deprioritize to use resources well: e.g., age at the extremes, terminally ill, chronically ill with a life-threatening disease.” ,


Advocates for people living with disabilities and the elderly have protested these suggestions for deprioritization as prejudiced or unfair. , Some of their responses rest on questionable denials that even serious disabilities really tend to reduce health or quality of life. A more straightforward response is egalitarian: there is something unequal and unfair when a person who has lived with worse health is deprioritized as such for important future health benefits.


Whether or not this egalitarian response works for “reprioritizing” disabilities, egalitarianism only bolsters the case for deprioritizing the elderly as such. They have already gotten their “fair innings” and lived for many years—they are “rich” in life years. By contrast, should the young die now, they will die without having had many life years and without the key life experiences those life years enable. In fact, while the elderly do not always have lower life expectancy than all young people (some young people are terminally ill), and while the elderly’s potential contemporaneous vulnerability can lend them priority from some egalitarian viewpoints, , the “fair innings” argument uniformly supports giving priority to the young.


Because complex philosophical considerations may deprioritize the youngest patients (neonates, and perhaps infants and children), some have proposed that fairness gives people who are in the prime of their lives, with life plans and persons who are fully developed yet seldom fulfilled, somewhat higher priority than it does to either the very old or the very young.


It may seem as although the procedural prohibition on partiality and discrimination that we mentioned renders these complexities moot. Disaster responders are often warned against any discrimination on the basis of personal relations, race, religion, economic status, geographic location, sex, and some other attributes, any of which would count as partial. Does this prohibition rule out any consideration of disability status or age? A lot depends on precisely what it makes sense to deem irrelevant for disaster triage. First, the World Medical Association regards only nonmedical characteristics as irrelevant, and one could argue that age or at least disability status are medical characteristics. On the other hand, for the International Federation of Red Cross and Red Crescent Societies, only “medical need” (or elsewhere: “need”) should make a difference, and one could argue that those living with disabilities or the elderly have an equal need to live. That having been said, it is philosophically complex whether, when the medical benefits following survival are unequal, medical needs in survival remain equal.


A second response emphasizes that “an ethical policy does not require that all persons be treated in an identical fashion, but does require that differences in treatment be based on appropriate differences among individuals.” The response adds that the person’s own medical need is not the only legitimate ground for favorable treatment. What matters for avoiding partiality is that “this priority should stem from … relevant factors,” and these factors can transcend personal medical need. For example, they include also “important community goals, such as helping first responders or other key personnel stay at work.” To accept this logic would render the question whether medical need is similarly less crucial.


Response Worker Prioritization


Should disaster triage give first responders and other key personnel priority for treatment and prophylaxis? Many documents suggest as much, on a number of grounds:




  • Only healthy, able relief staff can help minimize morbidity and mortality for all—so all benefit from this potential inequality.



  • Only well-protected relief staff are likely to want to stay in dangerous environments. For example, whether or not morally their obligation is to show up to work even during pandemic flu, health workers who know that they (and their families) are inoculated are likelier to do so.



  • Response teams often face higher risk than the general population, for instance, of infection, burns (for firefighters), a building collapsing further, or a second bomb exploding. It is only fair to pool this elevated risk by providing response teams with added protection and priority for treatment, thereby reestablishing more equal chances at life.



  • Response teams deserve societal gratitude for their often taxing or brave services. Priority for health services is one way to thank them.



However, some disagree that response personnel should be prioritized in every disaster situation. They warn that such automatic priority may look partial and undermine societal trust in that personnel.


Nondisaster Needs


In the aftermath of the 2010 Haiti earthquake, a foreign volunteer response team faced the following dilemma: Seven-year-old Haitian twins reached the hospital, both with broken left legs. One had been trapped under rubble and debris during the earthquake and the other was not affected by the earthquake but fell off of a tree while playing (example courtesy of MGH Disaster Relief Ethics Group). Was it ethical to attend to both twins and not just to the former, although the mission had been defined, and explained to donors, as one about disaster relief?


This question arises on a larger scale as well. Many humanitarian organizations use leftover funds from one disaster response mission for others. Money earmarked for tsunami response in South Asia was sometimes used for famine relief in Africa. Would it have been preferable to use the extra funds to build improved health systems in South Asia—not exactly a matter of disaster response either?


Given that systems are overburdened during disaster, the job of disaster responders can certainly extend beyond disaster response in the strictest sense. It can include preventing escalation, for example, in terms of later food insecurity and securing continuous routine immunizations, protection from mosquito exposure, and so forth. While a full theory remains necessary on the exact scope of rescue work, part of the expectation is that this work will go beyond disaster response in the narrowest sense.


Repeat Triage


“Since cases may evolve and thus change category, it is essential that the situation be regularly reassessed by the official in charge of the triage.” One interesting implication is that patients previously triaged not to receive immediate care can later be repeat-triaged to receive care immediately. A more striking implication is that patients previously allotted care may lose that entitlement. That implication can be very hard for caretakers and families to accept. However, in a disaster, at least, “policies permitting the withdrawal of critical care treatment to reallocate to someone else based on higher likelihood of benefit may be ethically permissible.” The main question concerns the exact circumstances that make such reallocation permissible. Are disaster triage criteria for withdrawal of treatment strictly equivalent to the ones for its withholding or moderately more complicated? Either way, treatment withdrawal aimed at saving other patients will often remain appropriate in a disaster, such as during a pandemic flu in which the number of patients in need of ventilators is twice the number of available ventilators, and training should prepare health workers and triage teams for it.



Disparities


Disasters tend to affect minorities, the poor, women, and other vulnerable or marginalized groups more than they do social elites. The former are more vulnerable to disastrous events (flooding washes away hillside slums more than it does hilltop villas, and women take care of children more than their husbands do). They face greater difficulties obtaining good services—the poor may lack funds for paying private physicians or purchasing vehicles for reaching public hospitals first.


Response planners should remain “mindful of existing health disparities that may affect populations or regions” and make advance plans to mitigate or redress them. They may, for example, organize added public transportation in poor neighborhoods, boost translation services, and set up regular briefings with minority representatives to glean information on barriers to equitable response efforts. , Addressing disparities at the level of individual triage is inappropriate and sometimes too late.



Quarantine


Public health interests can be in tension with the interests, needs, liberties, or rights of individuals, and disasters can bring these tensions into sharp relief. When a disaster consists of infectious disease outbreaks, containment sometimes benefits from geographic isolation of infected individuals, social distancing measures (e.g., bans on public gatherings), border controls and travel bans, and, most controversially in modern times, quarantine, the geographic isolation of individuals considered to be at a sufficiently high likelihood of being infected.


The “health and human rights” approach tends to play down clashes between public health and individual rights. It points out the complications for public health when the individuals whose collaboration is needed for reporting, self-transport, containment, and grassroots-level mutual assistance are antagonized or fearful that collaboration might cost them direly—for example, that seeing a doctor is likely to land them in quarantine. In the 2014-2015 Ebola outbreak in West Africa, attempts to place areas under quarantine floundered: against a background of distrust as well as insufficient supplies in many quarantined areas, individuals kept breaking the quarantine. Health and human rights lawyers emphasize that quarantine has greater chances of success when individuals receive food and other supplies, there is constant attention to their evolving needs, and quarantine is voluntary not mandatory.


It is true that in some ways protection of personal rights provides good collective outcomes. But it is also true that that is not always the case. Arguably, in the same West African Ebola crisis, early quarantine could have contained Ebola, as it regularly does in East Africa, where it has been used successfully against Ebola for decades.


There is no reason, of course, to make measures transgressing individual liberty or interests worse than they need be: “Any measures that limit individual rights and civil liberties must be necessary, reasonable, proportional, equitable, nondiscriminatory, and not in violation of national and international laws.” , Such measures should respect due process and “least restrictive alternative” requirements. They should be regularly reassessed in light of evolving evidence. , The interests of affected individuals should be promoted as much as possible, to maintain equality or reciprocity —and not just by securing enough food and safety. Luxury hotels were said to work just as well for quarantine. Post hoc compensation or apology can make sense. Yet there is no logical reason why there could not be clashes between collective disaster response interests and individual interests.


On those rare occasions that clashes are inevitable, the approach that is common in contemporary ethics is that there are no absolute rules—including rules forbidding intrusive quarantine, etc. Utilitarians and other consequentialists recognize no rules constraining the pursuit of maximal utility and other good consequences. But even nonconsequentialist thinkers, who believe that some rules should be respected, nearly always agree that these rules are not absolute. Disaster situations in which scores of lives are at stake clearly are the paradigm cases in which there is a sufficient case for transgression of moral rules.


But clashes between public health interests and those of individuals are not just rare. The history of quarantine and other travel restrictions disproportionally affecting minorities and marginalized migrants has another potential lesson to tell. Many seeming clashes between public health and personal rights are not genuine clashes. They could have been reconciled otherwise. One way forward is therefore to use quarantine and other measures that limit personal rights and welfare, but to do so as sparsely and as minimally as possible, while making their (continuing) use subject to multiple external approvals, thereby guarding against partiality and prejudice. A standing international body or respected public health experts from remote regions could be appointed during disaster planning for approval positions.



Surveillence


Postdisaster surveillance is crucial for assessing what works to overcome an infection—which is crucial so long as very regular meetings to reassess and change practice in light of new evidence actually take place. Here again, a tension arises between a public health need and a personal need—in this case, a personal need of privacy and confidentiality. How does one ensure that identifiable patient information is not accidentally divulged? Should reporting be mandatory? Just as we observed in relation to quarantine, here too the tension is attenuated by some overlap in public and individual needs. For example, there is also a public health interest in maintaining confidentiality, which encourages people to come forth and provide information. To some degree therefore the tension is between different factors affecting one ethical desideratum—effective disaster response that protects the public’s health—and empirical studies may help settle which effect is stronger, under which circumstances.



Research


Just as surveillance is crucial in a disaster, more rigorous studies are also crucial. Medical, implementation, and public health studies can help develop countermeasures and evaluate them safely and reliably—for the ongoing disaster and for better response in similar later situations (see Chapter 60 ).


In the 2014 Ebola outbreak, some scholars supported rigorous research, even if it involved individually randomized control trials. , , Others proposed ways to temper scientific rigor with what they saw as compassion, and they emphasized logistical complications in individual randomization. , Further scholarship on this complex question remains necessary.



Rescuers’ Rights


The American Medical Association medical code states, “Individual physicians have an obligation to provide urgent medical care during disasters. This ethical obligation holds even in the face of greater than usual risks to their own safety, health or life.” Different authors penned much stronger , or much weaker , , statements of physicians’ and other response workers’ right to prioritize personal interests and health over effective disaster response. What seems to be generally agreed is that moral “demandingness” is far higher for health workers than for the general public. Health workers will have often taken the Hippocratic oath, accepted societal esteem and benefits, and invited social trust that they will be available if needed. We all now rely on them.



Transparency and Communication


To remain accountable, to preserve public trust, to facilitate public feedback, to allow coordination between different organizations, and to show respect to stakeholders (including voters, affected populations, and disaster personnel), it is usually best to maintain transparency about disaster planning and operations, , including the rationing principles being used. , However, media relations and public health risk communication are intricate matters, and it is by no means self-evident that maximal transparency will always be the most effective way to maintain public trust, cooperation, and calm. Those matter, too. During a disaster, they can translate into many lives saved. Unbridled transparency also risks violating patients’ privacy, presenting affected populations as helpless victims without substantial agency, and even exacerbating stereotypes against stigmatized social groups. ,


What is more straightforwardly a net gain is communication flow from the public to disaster managers. Collection of public input on ethical and other aspects on disaster planning and response (e.g., a process for public comments on a website) can help planners gather ideas and responders receive real-time alerts about response breakdowns.


Some have proposed a more ambitious process of public deliberation and participation in expert decision making. , , Disaster response is the wrong time for elaborate deliberative polls, which are very time consuming. Even during the planning period, it is not clear how valuable the process as currently envisaged would be. Intense discussions over days are resource intensive and can only happen with small samples, making the findings statistically less interpretable. Even then, a couple of days’ education does not create expertise on these intricate matters, yet many lives hang on these decisions. It has been said that “people will be more likely to cooperate, and accept difficult decisions made by their leaders for the common good” if community representatives are at the negotiating table. But experts appointed democratically already do that, and many people will not have even heard that disaster plans rest on joint decision. Where deliberation clearly would help is in collecting diverse perspectives as input to inform expert planning. But perspectives input can be collected in the simpler ways noted earlier.



Political Involvement


Engagement in political debates raises other complexities. On the one hand, it risks losing disaster response workers their crucial reputation for neutrality, which buys them broad support from patients, donors, and sometimes literally warring political factions. Such involvement clearly goes beyond workers’ tacit mandate of disaster response in a strict sense. In fact, response workers can feel cheated and instrumentalized when their missions turn out to serve long-term organizational or political goals. Although there is no absolute rule against this brand of long-term organizational or political thinking, it should remain rare. Certainly one should not compromise patient care for political gain, for example, by rejecting enemy combatants or terrorists in order to advance organizational popularity and donations.


That said, disaster responders are in a good position to advise the public on certain political decisions. They may lobby to provide generous international aid during disasters abroad, to release vaccine stockpiles for international use, and to avoid scientifically unfounded, automatic quarantining of all returning health workers.


This tension, between political engagement and an image of neutrality, is genuine and hard to avoid. The IFRC embraces, among other things, a mission of changing minds and promoting a safer culture of social inclusion, and it calls for national legal preparedness and international legal cooperation through the development and promotion of disaster laws, principles, and rules. These are important agendas. They are also ones with political ramifications. In some future situations, they may turn out to threaten the organization’s principle of neutrality.



Recovery


During disaster recovery, evacuees return home, regular civil services and normality are restored, and ethical tasks can be completed.


Disasters put a strain on many things we value: on societal trust in health workers, who must provide care below normal standards; on local and national sovereignty, which can be threatened by the aid coming from metropolitan national and international centers ; and on the dignity, standing, and perceived agency of affected populations, which will have often been presented in the media as victims, and of marginalized social groups, which will have often been blamed as the causes of the disaster. In particular, recovery provides an occasion for international organizations to return any doctors they will have hired to the local public service and to allow that service to assume responsibility for all roles—the most sustainable solution in the long run.


Disaster recovery can also be used for system improvement. Although systems will often be compromised or destroyed by the disaster, the rescue mentality, mentioned earlier, will still be there, along with some donations and psychological momentum. This is when the circumstances of disaster can be mobilized to achieve lasting, substantial increases in health and welfare—prophylactically rather than only in hindsight—so that vulnerabilities that gave rise to a disaster are removed and cost-effective interventions to improve the public’s health are firmly in place.

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Aug 25, 2019 | Posted by in EMERGENCY MEDICINE | Comments Off on Ethical Issues in Disaster Medicine
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