Facing Ethical Challenges, Dealing with Outcomes: Stories from the Field

1. Facing Ethical Challenges, Dealing with Outcomes: Stories from the Field Harvey Kayman, MD, MPH, PHMO III University of California, Berkeley California Department of Public Health

2. Learning Objectives • List and describe public health ethical principles and an ethical framework to resolve moral tensions disasters might bring up • Review scenarios that will illustrate how the framework and principles can be used • Develop methods to make decisions with collaborators in the midst of a disaster

3. Biomedical and Public Health Ethics Personal autonomy vs. the common good Obligation vs. responsibilities Autonomy Beneficence Beauchamp, TL, Childress, JF. Principles of Biomedical Ethics. Oxford University Press, New York, any edition.

4. Biomedical and Public Health Ethics (cont) Non maleficence, minimize harm Justice Authority and decision making Least unfair distribution of benefits and burdens http://plato.stanford.edu Kayman, H, Ablorh-Odjidja, A. Revisiting Public Health Preparedness: Incorporating Social Justice Principles Into Pandemic Preparedness Planning for Influenza J Public Health Management Practice. 2006. 12(4), 373–380.

5. transparency inclusion in decision-making process accountability precautionary principle Kurland, J. Editorials and The Heart of the Precautionary Principle in Democracy.Public Health Reports. 2002. Nov–Dec. 117,491–500.

6. The Precautionary Principle Action, even coercive action, must be taken when there is a serious threat to the public’s welfare, often in the face of uncertainty.

7. Personal autonomy and the common good Least unfair distribution of benefits and burdens Jay Johnson Rob Elkins

8. Obligation and responsibilities Mark Oberle

14. Authority and decision making Carl Osaki

15. Poll Question Have you encountered any situations similar to these in your work? Yes Sort of No No, but I have encountered other kinds of ethical dilemmas Click on the down arrow if you can’t see the response choices.

16. Poll Question Do you have a mechanism for handling ethical dilemmas such as these in your workplace? Yes Sort of No No, but I have some ideas of how we might handle these situations Click on the down arrow if you can’t see the response choices.

17. Decision Making and Problem Solving Step 1 Identify the problem Step 2 Explore alternatives Step 3 Select an alternative Step 4 Implement the solution Step 5 Evaluate the situation FEMA IS 241

18. Step 1. Identify the Problem Protocol for Decision Making in the Midst of Crises: Role of Convener Gather & discusswith participantstrained to usemethod Determine that adecision must be made Define problem clearly Assure data are accurate, complete and up to date Gather all pertinent data Describe desiredoutcomes Proposed by Harvey Kayman, with adaptations from FEMA IS 241

19. Step 1: Identify the Problem Protocol for Decision Making in the Midst of Crises: Role of Convener Gather appropriate stakeholders Present data from evidence, models, & expert input Describe problem, resources, and desired outcome Discuss & analyze problem, data, and options Describe timeframe to implementation Proposed by Harvey Kayman, with adaptations from FEMA IS 241

20. Step 2: Evaluate Alternatives • Does this solution fit the circumstances? • Is the action worth doing? • Will this option meet the objectives? • Has the cost/benefit ratio been considered? FEMA IS 241

21. Step 2: Evaluate Alternatives Identify Constraints Technical Political Safety Financial Social Human resources Environ-mental Time urgency Legal Ethical FEMA IS 241

22. Step 2: Evaluate Alternatives Checklist of Questions to Consider • If you should take on the responsibilities, who are your important partners, other stakeholders, consultants, etc.? • Do you have the data to support your choices? • Do you have the capacity to deliver the resource? • If not, what materials, resources and trainings are needed to expand capacity? Proposed by Harvey Kayman, with adaptations from FEMA IS 241

23. Step 2: Evaluate Alternatives Ethical Questions to Consider (cont) • Is your decision about resource allocation equitable or does that matter? • Will it result in the “least unfair” distribution of benefits and burdens? • What gives you the authority to make this decision? Proposed by Harvey Kayman, with adaptations from FEMA IS 241

24. Step 2: Evaluate Alternatives Ethical Questions to Consider • Do you have the time and expertise to examine for bias? • Will implementation interfere with some group’s autonomy in support of the common good? • What are potential consequences: negative, positive, undesired, not anticipated in the past, etc.? Proposed by Harvey Kayman, with adaptations from FEMA IS 241

25. Professionalism Social Solidarity attachment interdependence shared beliefs commitment involvement public order subsidiarity safety common good ready access evidence based competence consistency adaptive consensus driven duty to act reciprocity transparency integrity Justice informed consent/refusal disclosure/truth-telling nonmaleficence confidentiality beneficence stewardship autonomy equality equity difference principle proportionality due process liberty J. F. Tuohey. A Matrix for Ethical Decision Making in a Pandemic. The Oregon Tool for Emergency Preparedness. Health Progress 88 (6) November–December 2007

26. Step 3: Select an Alternative Determine Objectives Used to monitor progress and establish priorities Based on analysis of the situation and contingencies Objectives: measurable targets

27. Step 4: Implement the Solution Develop an Action Plan • Identify needed resources: • How much will it cost? • Do you have the money to support implementing your decisions? • If not, can you get the money in time? • What is the likely source of funding? • Will your partners provider in kind resources? Proposed by Harvey Kayman, with adaptations from FEMA IS 241

28. Step 4: Implement the Solution Build a Plan • Who? • Will do what? • With whom? • By when? • Where? • How? FEMA IS 241

29. Step 5: Evaluate the Situation Later Steps Adapt for use by others Create after action report Share knowledge with others Evaluate process Improve as needed Proposed by Harvey Kayman, with adaptations from FEMA IS 241